Exam (elaborations)

Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson

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Course
Health assessment

Institution
Health Assessment

Chapter 01: Introduction to Health Assessment MULTIPLE CHOICE 1. A patient comesto the emergency department and tells the triage nurse that he is “having a heart attack.” What isthe nurse’s top priority at this time? a. Determine the patient’s personal data and insurance coverage. b. ...

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Uploaded on January 28, 2025
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wilson
health assessment for nursing practice

Institution Health assessment
Course Health assessment

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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 he
is “having a heart attack.” What is the nurse’s top priority at this time?
a. Determine the patient’s personal data and
insurance coverage.
b. Ask the patient to take a seat in the waiting
room until his name is called.
c. Request that a nurse collect data for a
comprehensive history.
d. Ask a nurse to start a focused assessment
of this patient now.
ANSWER: D
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
cardiovascular system. The type of health assessment performed by the nurse is also driven
by 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. 3
TOP: 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 detailed
history and physical examination.
b. A hospital sponsors a health fair at a local
mall and provides cholesterol and blood
pressure checks to mall patrons.
c. The nurse in an urgent care center checks
the vital signs of a patient who is
complaining of leg pain.

, d. A patient newly diagnosed with diabetes
mellitus 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 example
of 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. 3
TOP: 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 surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: B
A screening assessment is performed for the purpose of disease detection. In this case this
person 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 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 the procedure.

DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities

4. For zwhich zperson zis za zshift zassessment zindicated?
a. The zperson zwho zhad zabdominal
zsurgeryzyesterday

b. The zperson zwho zis zunaware zof zhis
zhighzserum zglucose zlevels

c. The zperson zwho zis zbeing zadmitted zto za
long-term zcare zfacility
d. The zperson zwho zis zbeginning
zrehabilitationzafter za zknee zreplacement

ANSWER: z A
A zshift zassessment zis zmost zappropriate zfor zthe zperson zwho zis zrecovering zin zthe
zhospital zfromzsurgery. zA zscreening zassessment zis zperformed zfor zthe zpurpose zof
zdisease zdetection, zin zthis zcase zdiabetes zmellitus. z A zcomprehensive zassessment zis
zperformed zduring zadmission zto za

, facility zto zobtain za zdetailed zhistory zand zcomplete zphysical zexamination. zAn
zepisodic zor zfollow-up zassessment zis zperformed zafter zknee zreplacement zto zevaluate
zthe zoutcome zof zthezprocedure.

DIF: z z zCognitive zLevel: zUnderstand REF: zBox z1-3 z|
zp. z4zTOP: zNursing zProcess: zAssessment
MSC: zNCLEX zPatient zNeeds: zSafe zand zEffective zCare zEnvironment: zManagement zof zCare:
zEstablishing zPriorities

5. For zwhich zperson zis za zcomprehensive zassessment zindicated?
a. The zperson zwho zhad zabdominal
zsurgeryzyesterday

b. The zperson zwho zis zunaware zof zhis
zhighzserum zglucose zlevels

c. The zperson zwho zis zbeing zadmitted
zto zazlong-term zcare zfacility

d. The zperson zwho zis zbeginning
zrehabilitationzafter za zknee zreplacement
ANSWER: zC
A zcomprehensive zassessment zis zperformed zduring zadmission zto za zfacility zto zobtain za

detailed zhistory zand zcomplete zphysical zexamination. zA zshift zassessment zis zmost
zappropriatezfor zthe zperson zwho zis zrecovering zin zthe zhospital zfrom zsurgery. zA
zscreening zassessment zis zperformed zfor zthe zpurpose zof zdisease zdetection, zin zthis
zcase zdiabetes zmellitus. zAn zepisodic zor zfollow-up zassessment zis zperformed zafter
zknee zreplacement zto zevaluate zthe zoutcome zof zthe zprocedure.

DIF: z z zCognitive zLevel: zUnderstand REF: zBox z1-3 z|
zp. z3zTOP: zNursing zProcess: zAssessment
MSC: zNCLEX zPatient zNeeds: zSafe zand zEffective zCare zEnvironment: zManagement zof zCare:
zEstablishing zPriorities

6. For zwhich zperson zis zan zepisodic zor zfollow-up zassessment zindicated?
a. The zperson zwho zhad zabdominal
zsurgeryzyesterday

b. The zperson zwho zis zunaware zof zhis
zhighzserum zglucose zlevels

c. The zperson zwho zis zbeing zadmitted zto za
long-term zcare zfacility
d. The zperson zwho zis zbeginning
zrehabilitationzafter za zknee zreplacement

ANSWER: z D
An zepisodic zor zfollow-up zassessment zis zperformed zafter zthe zknee zreplacement zto
zevaluate zthe zoutcome zof zthe zprocedure. zA zshift zassessment zis zmost zappropriate zfor
zthe zperson zwho ziszrecovering zin zthe zhospital zfrom zsurgery. zA zscreening zassessment
zis zperformed zfor zthe zpurpose zof zdisease zdetection, zin zthis zcase zdiabetes zmellitus. zA
zcomprehensive zassessment zis zperformed zduring zadmission zto za zfacility zto zobtain za
zdetailed zhistory zand zcomplete zphysicalzexamination.

DIF: z z zCognitive zLevel: zUnderstand REF: zBox z1-3 z|
zp. z3zTOP: zNursing zProcess: zAssessment

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