Health Physical - Fourth Edition Cynthia Fenske Katherine Watkins...

Test Bank Health & Physical Assessment in Nursing Fourth Edition Cynthia Fenske Katherine Watkins Tina Saunders Donita D’Amico Colleen Barbarito 1 / 4

1 Copyright © 2020 PearsonEducation, Inc.Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 1 Health Assessment 1)A client with a self-reported history of type 2 diabetes mellitus and an ulcer wound on the left foot states to the nurse, "I am healthy, I don't know why I have to be here to get a check-up." Which statement by the nurse is the most appropriate?

• "I feel that you are in denial about your health status."
• "Tell me about your definition of being healthy."
• "Do you understand what diabetes is?"
• "Is there anything else you are not telling me?"

Answer: 2

Explanation: 1. More information would be needed before the nurse could attribute the client's viewpoint as denial or lack of knowledge.

• During the process of gathering the subjective data from the client, the nurse must be

attuned to what the patient says, along with the signs, symptoms, behaviors, and cues offered by the patient. This situational awareness and focused data collection will enable the nurse to create a comprehensive database about the patient.

• The client's history of type 2 diabetes requires further investigation but the nurse must first

ascertain the client's definition of what healthy means.

• There is not enough information to determine the client's withholding of information to the

nurse.

Page Ref: 4

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Illness Management

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing. 2 / 4

2 Copyright © 2020 PearsonEducation, Inc.2)The nurse is preparing to provide teaching to a client at risk for diabetes. During which time should the nurse recognize is the most effective moment for teaching?

• During health promotion.
• When the client is ready to learn.
• During the discussion of disease prevention.
• When a knowledge deficit has been identified.

Answer: 2

Explanation: 1. Health promotion is important; however, if the client is not ready to learn new information, the teaching may be ineffective.

• A client must be ready to learn new information or the teaching may be ineffective.
• Disease prevention is important; however, if the client is not ready to learn new information,

the teaching may be ineffective.

• Once the knowledge deficit is identified, it is important that client is ready to learn or the

teaching may be ineffective.

Page Ref: 2

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health; communicate information effectively; and listen openly and cooperatively. | Nursing/Integrated Concepts:

Nursing Process: Planning

Learning Outcome: 1.3: Explain the steps of the nursing process.MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare. 3 / 4

3 Copyright © 2020 Pearson Education, Inc.3) The nurse is conducting a workshop on wellness and health promotion using the initiatives of Healthy People 2020. After the session, which statement by a participant indicates an understanding of the initiatives?

• "It will allow healthcare providers to lobby legislators for more funding."
• "The primary goal of Healthy People 2020 is to assist healthcare providers in determining risk

factors for premature birth."

• "Healthy People 2020 seeks to promote health, prevent illness, disability, and premature

death."

• "The initiatives will outline standards of care for providers in managing diseases."

Answer: 3

Explanation: 1. Healthcare providers and other persons interested in programs to promote health have found the document to be a useful source of information in their efforts to gain funding.

• The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent

illness, disability, and premature death. The document identifies leading health indicators that reflect public health concerns. Risk factors for premature birth may be part of those health indicators, but the scope of the document covers broad areas of concern.

• The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent

illness, disability, and premature death.

• Standards of care in disease management is not a component of the document.

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care; patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.6: Describe the concepts of health, wellness, and health disparities.MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

• / 4