Test Bank for Health Assessment for Nursing Practice 7th edition by Susan Fickertt Wilson & Jean Foret Giddens,
Chapter 1-24, ISBN No; 9780323797665 (NEWEST 2024)
STUDYGUIDESOLUTIONS
,Test Bank for Health Assessment for Nursing Practice 7th edition by Susan Fickertt Wilson & Jean Foret Giddens,
Chapter 1-24, ISBN No; 9780323797665 (NEWEST 2024)
Chapter 01: Introduction to Health Assessment
Wilson: Health Assessment for Nursing Practice, 7th Edition
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 top priority at this time?
a. Determine the 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. ANS: D
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
patient to wait, the nurse needs to begin data collection, such as vital signs, immediately to determine the
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.
ANS: B
STUDYGUIDESOLUTIONS
,Test Bank for Health Assessment for Nursing Practice 7th edition by Susan Fickertt Wilson & Jean Foret Giddens,
Chapter 1-24, ISBN No; 9780323797665 (NEWEST 2024)
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
STUDYGUIDESOLUTIONS
,Test Bank for Health Assessment for Nursing Practice 7th edition by Susan Fickertt Wilson & Jean Foret Giddens,
Chapter 1-24, ISBN No; 9780323797665 (NEWEST 2024)
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
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 ANS: 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 which person is a shift 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 ANS: A
A shift assessment is most appropriate for 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. 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. 4 TOP: 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 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 ANS: C
STUDYGUIDESOLUTIONS
,A comprehensive assessment is performed during admission to a facility to obtain a detailed history and
complete physical examination. A shift assessment is most appropriate for 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. 3 TOP: 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 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 ANS: 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 is recovering 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 physical examination.
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
7. Which is an example of data a nurse collects during a physical examination?
a. The lack of hair and shiny skin over both shins
b. The stated concern about lack of money for prescriptions
c. The complaints of tingling sensations in the feet
d. The statements that the patient is very nervous lately ANS: A
The lack of hair and shiny skin over both shins are objective data or signs that are part of the physical
examination. lack of money are subjective data and are part of the health history.
tingling sensations in the feet are subjective data and are part of the health history.
A family statements are considered secondary data, are subjective data, and are part of the health
history.
STUDYGUIDESOLUTIONS
, Test Bank for Health Assessment for Nursing Practice 7th edition by Susan Fickertt Wilson & Jean Foret Giddens,
Chapter 1-24, ISBN No; 9780323797665 (NEWEST 2024)
DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3 TOP: Nursing Process: Assessment MSC:
NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments
8. The nurse documents which information in the history?
a. The skin feels warm to the touch.
b. The patient is scratching his arm.
c. The temperature is 100° F.
d. The patient complains of itching.
ANS: D
of itching is subjective information, which means it is a symptom and is documented
gathered by the nurse through observation, is also a sign, and is documented in the physical examination.
also a sign, and is documented in the physical examination.
DIF: Cognitive Level: Apply REF: p. 1 | p. 2 and Box 1-2 TOP: 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 physical assessment?
a. Slurred speech
b. Immunizations
c. Smoking habit
d. Allergies
ANS: 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 1-2 TOP: 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
STUDYGUIDESOLUTIONS
