Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson Chapter 1 - 24Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson Chapter 1 - 24Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson Chapter 1 - 24Test Bank for Health Assessment ...
Test Bank for Health Assessment for
IIll IIll IIll IIll IIll
IIll Nursing Practice 7th Edition by Wilson
IIll IIll IIll IIll IIll
IIll Chapter 1 - 24 IIll IIll IIll
,Chapter 01: Introduction to Health Assessment IIll IIll IIll IIll IIll
MULTIPLE CHOICE IIll
1. Apatient comesto the emergency department and tells the triage nurse thatIl IIll Il IIll IIll IIl IIll IIll IIll IIll I I ll IIll
II ll heis “having a heart attack.” What isthe nurse’s top priorityat this time?
Il IIll Il II ll IIll IIll IIll Il I I ll IIll IIll Il IIll IIll
a. Determine the patient’s personal data IIll IIll IIll IIll
andinsurance coverage. IIll Il IIll
b. Ask the patient to take a seat in the
IIll IIll IIll IIll IIll IIll IIll IIll
waitingroom until his name is called.
IIll Il IIll IIll IIll IIll IIll
c. Request that a nurse collect data for IIll IIll IIll IIll IIll IIll
acomprehensive history.
IIll Il II ll
d. Ask a nurse to start a focused IIll IIll IIll IIll IIll IIll
assessmentof thispatient now.
IIll Il IIll Il IIll
ANSWER: D IIll
The nurse needs to begin an assessment as soon as possible that is focused on this
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
patient’scardiovascular system. The type of health assessment performed by the nurse
IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
is also drivenby patient need. Personal data and insurance information will be
IIll IIll IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll
obtained, but in this situation, these data can wait until after the patient is assessed.
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
Based also on Maslow’s hierarchy of needs, physiologic needs take precedence.
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
Rather than asking the patient to wait, the nurse needs to begin data collection, such
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
as vital signs, immediately to determinethe patient’s health status. Complications can
IIll IIll IIll IIll IIll IIll Il IIll IIll IIll IIll IIll
be prevented if an immediate assessment is made to analyze the patient’s symptoms.
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
A comprehensive history is not indicated in this situation at this time. Some
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
subjective data will be collected, such as allergies and medical history related to
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
assessment is not a priority at this time.
Il IIll IIll IIll IIll IIl IIll IIll
DIF: Cognitive Level: Apply REF: Box 1-3 | p.
IIll IIll I I l l IIll IIll IIll IIll IIll IIll
3TOP: Nursing Process: Assessment
IIll Il IIll IIll IIll
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
Care:Establishing Priorities
IIll Il IIll
2. Which situation illustrates a screening assessment? IIll IIl Il I I ll IIl
a. A patient visits an obstetric clinic for the IIll IIll IIll IIll IIll IIll IIll
first time and the nurse conducts a IIll IIll IIll IIll IIll IIll IIl
detailedhistoryand physical examination. IIll Il Il IIll IIll
b. A hospital sponsors a health fair at a IIll II ll IIl IIll IIll IIll IIll
localmall and provides cholesterol and IIll Il IIll IIll IIll IIll
c. The nurse in an urgent care center IIll IIll IIll IIll IIll IIll
checksthe vital signs of a patient who IIll Il IIll IIll IIll IIll IIll IIll
is complaining of leg pain. IIll IIll Il IIll IIl
, d. A patient newly diagnosed with
IIll II ll IIll IIll
diabetesmellitus comes to test his
IIll Il IIll IIll IIll IIll
fasting blood glucose level.
IIll IIll IIll IIll
ANSWER: B IIll
A health fair at a local mall that provides cholesterol and blood pressure checks is an
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
example of a screening assessment focused on disease detection. A detailed history
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
and physical examination conducted during a first-time visit to an obstetric clinic is an
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
exampleof a comprehensive assessment. Assessing a patient complaining of leg pain in
IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
the triage area of an urgent care center is an example of a problem-based/focused
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
assessment. A patient’s return appointment 1 month after today’s office visit to report
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
fasting blood glucose levels is an example of an episodic or follow-up assessment.
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll II ll IIll
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
IIll IIll I I l l IIll IIll IIll IIll IIll IIll
3TOP: Nursing Process: Assessment
IIll Il IIll IIll IIll
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
IIll Il II ll I I ll Il IIll IIll IIll IIll
3. For which person is a screening assessment indicated?
IIll Il Il IIll II ll Il IIll
a. The person who had abdominal IIll IIll IIll IIll
surgeryyesterday IIll Il
b. The person who is unaware of his IIll IIll IIll IIll IIll IIll
highserum glucose levels
IIll Il IIll IIll
c. The person who is being admitted toIIll IIll IIll IIll IIll IIll
along-term care facility
IIll Il Il IIll
d. The person who is beginning IIll IIll IIll IIll
rehabilitationafter a knee replacement
IIll Il IIll IIll IIll
ANSWER: B IIll
A screening assessment is performed for the purpose of disease detection. In this case
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
thisperson may have diabetes mellitus. A shift assessment is most appropriate for the
IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
person who is recovering in the hospital from surgery. A comprehensive assessment
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
is performedduring admission to a facility to obtain a detailed history and complete
IIll IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
physical examination. An episodic or follow-up assessment is performed after knee
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
replacement toevaluate the outcome of the procedure.
IIll IIll Il IIll IIll IIll IIll IIll
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
IIll IIll I I l l IIll IIll IIll IIll IIll IIll
3TOP: Nursing Process: Assessment
IIll Il IIll IIll IIll
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
Care:Establishing Priorities
IIll Il IIll
4. For which person is a shift assessment indicated?
IIll Il IIll IIll I I ll IIll IIll
a. The person who had abdominal IIll IIll IIll IIll
surgeryyesterday IIll Il
b. The person who is unaware of his IIll IIll IIll IIll IIll IIll
highserum glucose levels IIll Il IIll IIll
c. The person who is being admitted to a IIll IIll IIll IIll IIll IIll IIll
long-term care facility Il IIll
d. The person who is beginning IIll IIll IIll IIll
rehabilitationafter a knee replacement IIll Il IIll IIll IIll
ANSWER: A IIll
A shift assessment is most appropriate for the person who is recovering in the hospital
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
fromsurgery. A screening assessment is performed for the purpose of disease
IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
detection, in this case diabetes mellitus. A comprehensive assessment is performed
IIll IIll IIll IIll IIll IIll I I ll IIll IIll IIll IIll
during admission to a
IIll IIl IIll IIll
, facility to obtain a detailed history and complete physical examination. An episodic
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
or follow-up assessment is performed after knee replacement to evaluate the outcome
IIll IIll IIll IIll IIl IIll IIll IIll IIll IIll IIll IIll
of theprocedure.
IIll IIll Il
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
IIll IIll I I l l IIll IIll IIll IIll IIll IIll
4TOP: Nursing Process: Assessment
IIll Il IIll IIll IIll
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
Care:Establishing Priorities
IIll Il IIll
5. For which person is a comprehensive assessment indicated?
IIll IIl IIl IIll IIll IIll IIll
a. The person who had abdominal IIll IIll IIll IIll
surgeryyesterday IIll Il
b. The person who is unaware of his IIll IIll IIll IIll IIll IIll
highserum glucose levels IIll Il IIll IIll
c. The person who is being admitted to IIll IIll IIll IIll IIll IIll
along-term care facility IIll Il Il IIll
d. The person who is beginning IIll IIll IIll IIll
rehabilitationafter a knee replacement IIll Il IIll IIll IIll
ANSWER: C IIll
A comprehensive assessment isperformed during admission to a facilityto obtain a
Il IIll IIll Il IIll IIl IIll IIll IIll Il IIll IIll
detailed history and complete physical examination. A shift assessment is most
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
appropriatefor the person who is recovering in the hospital from surgery. A screening
IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
assessment is performed for the purpose of disease detection, in this case diabetes
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
mellitus. An episodic or follow-up assessment is performed after knee replacement to
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
evaluate the outcome of the procedure.
IIll IIll IIll IIll IIll IIll
DIF: Cognitive Level: Understand REF: Box 1-3 | p.
IIll IIll I I l l IIll IIll IIll IIll IIll IIll
3TOP: Nursing Process: Assessment
IIll Il IIll IIll IIll
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
Care:Establishing Priorities
IIll Il IIll
6. For which person is an episodic or follow-up assessment indicated?
IIll Il IIll IIll Il IIll IIll IIll IIll
a. The person who had abdominal IIll IIll IIll IIll
surgeryyesterday IIll Il
b. The person who is unaware of his IIll IIll IIll IIl IIll IIll
highserum glucose levels IIll Il IIll IIll
c. The person who is being admitted to a IIll IIll IIll IIll IIl IIll IIll
long-term care facility Il IIll
d. The person who is beginning IIll IIll IIll IIll
rehabilitationafter a knee replacement IIll Il IIll IIll IIll
ANSWER: D IIll
An episodic or follow-up assessment is performed after the knee replacement to
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
evaluate the outcome of the procedure. A shift assessment is most appropriate for the
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
person who isrecovering in the hospital from surgery. A screening assessment is
IIll IIll IIll Il IIll IIll IIll IIll IIll IIll IIll IIll IIll
performed for the purpose of disease detection, in thiscase diabetes mellitus. A
IIll IIll IIll IIll IIll IIll IIll IIll Il Il IIll IIll IIll
comprehensive assessment is performed during admission to a facility to obtain a
IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll IIll
detailed history and complete physicalexamination.
IIll IIll IIll IIll IIll Il
DIF: Cognitive Level: Understand
IIll IIll I I l l IIll IIll REF: Box 1-3 | p. IIll IIll IIll IIll
3TOP: Nursing Process: Assessment
IIll Il IIll IIll IIll
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