HEALTH ASSESSMENT FOR NURSING PRACTICE 7TH EDITION

HEALTH ASSESSMENT FOR NURSING PRACTICE 7TH EDITION

JEAN FORET GIDDENS TESTBANK/ CHAPTER 1 -24/COMPLETE

GUIDE 2024-2025

• / 4

Chapter 01: Introduction to Health Assessment

Wilson: Health Assessment for Nursing Practice, 7th Edition

MULTIPLE CHOICE

• A client comes to the emergency department and tells the triage caregiver that he is

―having a heart attack.‖ What is the caregiver‘s top priority at this time?

• Determine the client‘s personal data and insurance coverage.
• Ask the client to take a seat in the waiting room until his name is called.
• Request that a caregiver collect data for a comprehensive history.
• Ask a caregiver to start a focused assessment of this client now.

SELECT ANSWER: - D

Feedback:->>The caregiver needs to begin an assessment as soon as possible that is focused on this client‘s cardiovascular system. The type of health assessment performed by the caregiver is also driven by client need. Personal data and insurance information will be obtained, but in this situation, these data can wait until after the client is assessed. Based also on Maslow‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the client to wait, the caregiver needs to begin data collection, such as vital signs, immediately to determine the client‘s health status. Complications can be prevented if an immediate assessment is made to analyze the client‘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 TOP:Nursing Process: Assessment MSC:NCLEX Client Needs: Safe and Effective Care Environment: Management of Care: Establishing Priorities

• Which situation illustrates a screening assessment?
• A client visits an obstetric clinic for the first time and the caregiver

conducts a detailed history and physical examination.

• A health center sponsors a health fair at a local mall and provides cholesterol and

blood pressure checks to mall patrons.

• The caregiver in an urgent care center checks the vital signs of a client who

is complaining of leg pain.

• A client newly diagnosed with diabetes mellitus comes to test his fasting blood

glucose level.

SELECT ANSWER:- B

Feedback:->>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 client complaining of leg pain in the triage area of an urgent care center is an example of a problem-based/focused assessment. A client‘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 TOP:Nursing Process: Assessment MSC:NCLEX Client Needs: Health Promotion and Maintenance: Health Screening

• For which person is a screening assessment indicated? 2 / 4

• The person who had abdominal surgery yesterday
• The person who is unaware of his high serum glucose levels
• The person who is being admitted to a long-term care facility
• The person who is beginning rehabilitation after a knee replacement

SELECT ANSWER:- B

Feedback:->>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 health center 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 TOP:Nursing Process: Assessment MSC:NCLEX Client Needs: Safe and Effective Care Environment: Management of Care: Establishing Priorities

• For which person is a shift assessment indicated?
• The person who had abdominal surgery yesterday
• The person who is unaware of his high serum glucose levels
• The person who is being admitted to a long-term care facility
• The person who is beginning rehabilitation after a knee replacement

SELECT ANSWER:- A

Feedback:->>A shift assessment is most appropriate for the person who is recovering in the health center 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 TOP:Nursing Process: Assessment MSC:NCLEX Client Needs: Safe and Effective Care Environment: Management of Care: Establishing Priorities

• For which person is a comprehensive assessment indicated?
• The person who had abdominal surgery yesterday
• The person who is unaware of his high serum glucose levels
• The person who is being admitted to a long-term care facility
• The person who is beginning rehabilitation after a knee replacement

SELECT ANSWER:- C

Feedback:->>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 health center 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. 3 / 4

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

• For which person is an episodic or follow-up assessment indicated?
• The person who had abdominal surgery yesterday
• The person who is unaware of his high serum glucose levels
• The person who is being admitted to a long-term care facility
• The person who is beginning rehabilitation after a knee replacement

SELECT ANSWER:- D

Feedback:->>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 health center 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 TOP:Nursing Process: Assessment MSC:NCLEX Client Needs: Safe and Effective Care Environment: Management of Care: Establishing Priorities

• Which is an example of data a caregiver collects during a physical examination?
• The client‘s lack of hair and shiny skin over both shins
• The client‘s stated concern about lack of money for prescriptions
• The client‘s complaints of tingling sensations in the feet
• The client‘s mother‘s statements that the client is very nervous lately

SELECT ANSWER:- A

Feedback:->>The lack of hair and shiny skin over both shins are objective data or signs that are part of the physical examination. A client‘s concerns about lack of money are subjective data and are part of the health history. A client‘s complaints of tingling sensations in the feet are subjective data and are part of the health history. A client‘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 TOP:Nursing Process: Assessment MSC:NCLEX Client Needs: Physiological Integrity: Reduction of Risk Potential: System Specific Assessments

• The caregiver documents which information in the client‘s history?
• The client‘s skin feels warm to the touch.
• The client is scratching his arm.
• The client‘s temperature is 100 F.
• The client complains of itching.

SELECT ANSWER:- D

• / 4