Chapter 01: Introduction to Health Assessment

Wilson: Health Assessment for Nursing Practice, 6th 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 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.

ANS: 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.

ANS: 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