Test Bank for Health Assessment for
Nursing Practice 7th Edition by
Wilson Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triage nurse
that heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
a. Determine the patient‘s personal data
andinsurance coverage.
b. Ask the patient to take a seat in the
waitingroom until his name is called.
c. Request that a nurse collect data
for acomprehensive history.
d. Ask a nurse to start a focused
assessmentof this patient now.
ANSWER: D
The nurse needs to begin an assessment as soon as possible that is focused on this
patient‘scardiovascular system. The type of health assessment performed by the
nurse is also drivenby patient need. Personal data and insurance information will
be obtained, but in this situation, these data can wait until after the patient is
assessed. Based also on Maslow‘s hierarchy of needs, physiologic needs take
precedence. Rather than asking the patient to wait, the nurse needs to begin data
collection, such as vital signs, immediately to determine the patient‘s health
status. Complications can be prevented if an immediate assessment is made to
analyze the patient‘s symptoms. A comprehensive history is not indicated in this
situation at this time. Some subjective data will be collected, such as allergies
and medical history related to cardiovascular disease. Eyes, ears, or a complete
musculoskeletal or mental health assessment is not a priority at this time.
DIF: Cognitive Level: Apply REF: Box 1-3 | p.
3TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
2. Which situation illustrates a screening assessment?
a. A patient visits an obstetric clinic for
the first time and the nurse conducts a
detailedhistory and physical
examination.
b. A hospital sponsors a health fair at a
localmall and provides cholesterol
and blood pressure checks to mall
patrons.
c. The nurse in an urgent care center
checksthe vital signs of a patient
who is complaining of leg pain.
, d. A patient newly diagnosed with
diabetesmellitus comes to test his
fasting blood glucose level.
ANSWER: B
A health fair at a local mall that provides cholesterol and blood pressure checks is
an example of a screening assessment focused on disease detection. A detailed
history and physical examination conducted during a first-time visit to an
obstetric clinic is an exampleof a comprehensive assessment. Assessing a patient
complaining of leg pain in the triage area of an urgent care center is an example of
a problem-based/focused assessment. A patient‘s return appointment 1 month
after today‘s office visit to report fasting blood glucose levels is an example of an
episodic or follow-up assessment.
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
3TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal
surgeryyesterday
b. The person who is unaware of his
highserum glucose levels
c. The person who is being admitted
to along-term care facility
d. The person who is beginning
rehabilitationafter a knee replacement
ANSWER: B
A screening assessment is performed for the purpose of disease detection. In this
case thisperson may have diabetes mellitus. A shift assessment is most
appropriate for the person who is recovering in the hospital from surgery. A
comprehensive assessment is performedduring admission to a facility to obtain a
detailed history and complete physical examination. An episodic or follow-up
assessment is performed after knee replacement toevaluate the outcome of the
procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
3TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
4. For which person is a shift assessment indicated?
a. The person who had abdominal
surgeryyesterday
b. The person who is unaware of his
highserum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning
rehabilitationafter a knee replacement
ANSWER: A
A shift assessment is most appropriate for the person who is recovering in the
hospital fromsurgery. A screening assessment is performed for the purpose of
disease detection, in this case diabetes mellitus. A comprehensive assessment is
performed during admission to a
,facility to obtain a detailed history and complete physical examination. An
episodic or follow-up assessment is performed after knee replacement to
evaluate the outcome of theprocedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
4TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
5. For which person is a comprehensive assessment indicated?
a. The person who had abdominal
surgeryyesterday
b. The person who is unaware of his
highserum glucose levels
c. The person who is being admitted
to along-term care facility
d. The person who is beginning
rehabilitationafter a knee replacement
ANSWER: C
A comprehensive assessment is performed during admission to a facility to obtain a
detailed history and complete physical examination. A shift assessment is most
appropriatefor the person who is recovering in the hospital from surgery. A
screening assessment is performed for the purpose of disease detection, in this
case diabetes mellitus. An episodic or follow-up assessment is performed after
knee replacement to evaluate the outcome of the procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
3TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
6. For which person is an episodic or follow-up assessment indicated?
a. The person who had abdominal
surgeryyesterday
b. The person who is unaware of his
highserum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning
rehabilitationafter a knee replacement
ANSWER: D
An episodic or follow-up assessment is performed after the knee replacement to
evaluate the outcome of the procedure. A shift assessment is most appropriate for
the person who isrecovering in the hospital from surgery. A screening assessment
is performed for the purpose of disease detection, in this case diabetes mellitus. A
comprehensive assessment is performed during admission to a facility to obtain a
detailed history and complete physicalexamination.
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
3TOP: Nursing Process: Assessment
,MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
7. Which is an example of data a nurse collects during a
physicalexamination?
a. The patient‘s lack of hair and shiny
skinover both shins
b. The patient‘s stated concern about lack
ofmoney for prescriptions
c. The patient‘s complaints of
tinglingsensations in the feet
d. The patient‘s mother‘s statements
that thepatient is very nervous lately
ANSWER: A
The lack of hair and shiny skin over both shins are objective data or signs that are
part of the physical examination. A patient‘s concerns about lack of money are
subjective data andare part of the health history. A patient‘s complaints of
tingling sensations in the feet are subjective data and are part of the health
history. A patient‘s family statements are considered secondary data, are
subjective data, and are part of the health history.
DIF: Cognitive Level: Apply REF: Box 1-3 | p.
3TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential:
SystemSpecific Assessments
8. The nurse documents which information in the patient‘s history?
a. The patient‘s skin feels warm to the
touch.
b. The patient is scratching his arm.
c. The patient‘s temperature is 100° F.
d. The patient complains of itching.
ANSWER: D
A patient‘s complaint of itching is subjective information, which means it is a
symptom and is documented in the history. The patient‘s warm skin is objective
information gathered by the nurse through palpation, is also a sign, and is
documented in the physicalexamination. The patient‘s scratching is objective
information gathered by the nurse through observation, is also a sign, and is
documented in the physical examination. The patient‘s elevated temperature is
objective information gathered by the nurse through measurement, is also a sign,
and is documented in the physical examination.
DIF: Cognitive Level: Apply REF: p. 1 | p. 2 and Box
1-2TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
9. Which patient information does the nurse document in the patient‘s
physicalassessment?
a. Slurred speech
b. Immunizations
c. Smoking habit
d. Allergies
,ANSWER: A
Slurred speech should be noticed by the nurse and documented as objective data in
the physical assessment. Data on immunizations are collected from the patient,
are subjective, and documented in the history. A smoking habit is information
that comes from the patient,making it subjective data that is documented in the
history. Allergies are information that come from the patient, making it subjective
data that is documented in the history.
DIF: Cognitive Level: Apply REF: p. 1-2 and Box 1-
2TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
10. After collecting the data, the nurse begins data analysis with which action?
a. Clustering data
b. Documenting subjective data
c. Reporting information to other health
teammembers
d. Documenting objective information
ANSWER: A
After collecting data, the nurse organizes or clusters the data so that the problems
appearmore clearly. To cluster data, the nurse interprets the assessment data
collected.
Documenting subjective data is necessary for the medical record, but does not
provide analysis. Before reporting data to health team members, the nurse clusters
and interprets data. Documenting objective data is necessary for the medical
record, but does not provideanalysis.
DIF: Cognitive Level: Understand REF: p. 4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management
of Care:Establishing Priorities
11. Which activity illustrates the concept of primary prevention?
a. Monthly breast self-examination
b. Annual cervical (Papanicolaou
test)examination
c. Education about living with asthma
d. Exercising three times a week
ANSWER: D
Exercising is an example of primary prevention that prevents disease from
developing by maintaining a healthy lifestyle. Monthly breast self-examination
is an example of secondary prevention and screening efforts to promote early
detection of disease. Annual cervical (Papanicolaou test) examination is an
example of secondary prevention and screening efforts to promote early detection
of disease. Teaching a patient how to live witha chronic disease such as asthma
is an example of tertiary prevention directed toward minimizing the disability
from chronic disease and helping the patient maximize his or herhealth.
DIF: Cognitive Level: Understand REF: Table 1-1 | p.
5-6TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
, 12. A nurse is teaching a patient how to manage chronic obstructive
pulmonarydisease (COPD). This intervention is an example of which level of
health promotion?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Risk factor prevention
ANSWER: C
Teaching a patient how to live with a chronic disease is an example of tertiary
prevention directed toward minimizing the disability from chronic disease and
helping the patient maximize his or her health. The focus of primary prevention is
to prevent a disease from developing by promoting a healthy lifestyle. Secondary
prevention consists of efforts to promote early detection of disease. Risk factor
prevention is part of primary prevention thatfocuses on preventing disease by
managing risk factors.
DIF: Cognitive Level: Understand REF: Table 1-1 | p.
5-6TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
13. Which activity illustrates the concept of secondary prevention?
a. Annual mammogram
b. Nutrition classes on low-fat cooking
c. Education on living with diabetes
mellitus
d. Cardiac rehabilitation after coronary
arterybypass surgery
ANSWER: A
A mammogram screens for breast cancer and is an example of secondary
prevention to promote early detection of disease. Nutrition classes are an
example of primary preventionto prevent a disease from developing by promoting
a healthy lifestyle. Education about diabetes mellitus is an example of tertiary
prevention directed toward minimizing the disability from chronic disease and
helping the patient maximize his or her health. Cardiac rehabilitation after
coronary artery bypass surgery is an example of tertiary prevention directed
toward minimizing the disability from chronic disease and helping the patient
maximize his or her health.
DIF: Cognitive Level: Understand REF: Table 1-1 | p.
5-6TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
14. A community organization sponsors a health fair to increase awareness
of coloncancer. At the health fair, colorectal cancer screening kits are distributed,
and health care professionals answer questions, take blood pressure, and
distribute literature. What level ofhealth prevention is being implemented by this
community organization?
a. Primary
b. Secondary
c. Tertiary
d. Risk factor
ANSWER: B
Secondary prevention consists of screening efforts to promote early detection of
disease —in this scenario, colorectal cancer and hypertension. Primary
,prevention is focused on preventing disease from developing through the
promotion of a healthy lifestyle. Tertiary
, prevention is directed toward minimizing the disability from chronic disease and
helping the patient maximize his or her health. Risk factor prevention is part of
primary preventionthat focuses on preventing disease by managing risk factors.
DIF: Cognitive Level: Apply REF: Table 1-1 | p.
5-6TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
P owered by TCP DF (www.t p
c d f. o rg )
, Chapter 02: Obtaining a Health History
MULTIPLE CHOICE
1. Which statement or question does the nurse use during the
introductionphase of the interview?
a. ―I‘m here to learn more about the
painyou‘re experiencing.‖
b. ―Can you describe the pain that
you‘reexperiencing?‖
c. ―I heard you say that the pain is ‗all
over‘your body.‖
d. ―What relieves the pain you are
having?‖
ANSWER: A
―I‘m here to learn more about the pain you‘re experiencing‖ is an example of the
introduction phase a nurse may use to explain the purpose of the interview to a
patient. ―Can you describe the pain that you‘re experiencing?‖ is an example of
part of a symptomanalysis that occurs in the discussion phase. ―I heard you say
that the pain is ‗all over‘ your body‖ is an example of a summary statement by the
nurse that occurs in the summary phase. ―What relieves the pain you are having?‖
is an example of part of a symptom analysis that occurs in the discussion phase.
DIF: Cognitive Level: Apply REF: Box 2-1 | p.
8-9TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
2. Which statement is appropriate to use when beginning an
interview with anew patient?
a. ―Have you ever been a patient in this
clinicbefore?‖
b. ―What is your purpose for coming
to theclinic today?‖
c. ―Tell me a little about yourself and your
family.‖
d. ―Did you have any difficulty
finding theclinic?‖
ANSWER: B
―What is your purpose for coming to the clinic today?‖ is an open-ended question
that focuses on the patient‘s reason for seeking care. ―Have you ever been a patient
in this clinicbefore?‖ is a close-ended question that yields a ―yes‖ or ―no‖
response. This question may be asked on the first visit, but not as an opening
question for a health interview. ―Tell me a little about yourself and your family‖
is an open-ended question, but it is too general, and itis at least two questions: one
about the patient and another about the family. ―Did you have