Test Bank For - Clinical Judgment Approach 4 th Edition By Shar...

Test Bank For Nursing Health Assessment A Clinical Judgment Approach 4 th

Edition By Sharon Jensen (All Chapters 1-30, 100% Original Verified, A+ Grade)

All Chapters Arranged Reverse:

30-1 This is The Original Test Bank For 4 th Edition, All other Files in The Market are Fake/Old/Wrong Edition. 1 / 4

Chapter 30: Head-to-Toe Assessment of Adult

1.A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new client. What would be the instructor's best response?A."A new client needs a more complete assessment." B."It is a better assessment than any other assessment." C."The comprehensive health assessment integrates all body systems and helps give the nurse an overall impression of the client's condition." D."You need to know what is going on with the client at that point in time."

ANS:C

Feedback: The comprehensive health assessment integrates all body systems; findings help the nurse form an overall impression of the client and the client's condition. While many new clients do need more complete assessments, there are times when new clients first require emergency or focused assessments. Comprehensive assessments are not qualitatively better than focused or emergency assessments if used at inappropriate times or settings. A focused assessment is just as likely to help the nurse determine what is going on with the client at that point in time as a comprehensive assessment is.PTS:1 REF:p. 962 OBJ:1 NAT:Client Needs: Health Promotion and Maintenance TOP:Chapter 30: Head-to-Toe Assessment of the Adult KEY:Integrated Process: Teaching/Learning BLM:Cognitive Level: Analyze NOT:Multiple Choice 2.When conducting a focused health assessment, the nurse asks questions specifically

targeting the client's:

A.culture.B.gender.C.sexual orientation.D.specific issues and symptoms.

ANS:D

Feedback: The nurse focuses questions on issues and symptoms specific to the client. In this way, the client is viewed as a person who has multiple things that are affected by the health status. These questions are related to the client's primary problems and concerns. A focused assessment does not ask questions specifically about culture, gender, or sexual orientation.PTS:1 REF:p. 960 OBJ:1 NAT:Client Needs: Physiological Integrity: Reduction of Risk Potential TOP:Chapter 30: Head-to-Toe Assessment of the Adult KEY:Integrated Process: Communication and Documentation BLM:Cognitive Level: Remember NOT:Multiple Choice 3.Students are learning about subjective data collection. What data are collected subjectively?(Select all that apply.) A.Risk factors B.Common symptoms C.Family history 2 / 4

D.Auscultated sounds E.Visualized signs

ANS:A, B, C

Feedback: Subjective data collection includes health promotion, risk factors, history of present problem, past medical and family histories, personal and social histories, and common symptoms. Auscultated sounds and visualized signs are part of objective data collection.PTS:1 REF:p. 960 OBJ:2 NAT:Client Needs: Health Promotion and Maintenance TOP:Chapter 30: Head-to-Toe Assessment of the Adult KEY:Integrated Process: Nursing Process BLM:Cognitive Level: UnderstandNOT:Multiple Select 4.When collecting subjective data, the nurse gives the client time and encouragement to do what?A.Tell stories about his or her family B.Express complaints C.List common findings D.Tell about the client's concerns

ANS:D

Feedback: The nurse gives the client time and encouragement to tell their story and experience of health or illness. Doing so provides an opportunity for the client to express concerns; it often forms the foundation for a therapeutic relationship. Subjective data collection involves learning about the client's family history and health concerns, but the nurse would steer the conversation away from social discussions of the client's family or too many unrelated complaints. Common findings are part of objective data collection and are driven by the health provider, not the nurse.PTS:1 REF:p. 960 OBJ:2 NAT:Client Needs: Health Promotion and Maintenance TOP:Chapter 30: Head-to-Toe Assessment of the Adult KEY:Integrated Process: Nursing Process BLM:Cognitive Level: UnderstandNOT:Multiple Choice 5.A nursing instructor is explaining to students about primary prevention services that nurses offer as part of their professional responsibilities. What would the instructor list as these services?A.Palpation B.Auscultation C.Screening D.Rehabilitation

ANS:C

Feedback: Screening and resulting teaching are primary prevention services that nurses offer as part of their professional responsibilities. Palpation and auscultation are techniques of physical examination. Rehabilitation is a tertiary prevention service. 3 / 4

PTS:1 REF:p. 962 OBJ:3 NAT:Client Needs: Health Promotion and Maintenance TOP:Chapter 30: Head-to-Toe Assessment of the Adult KEY:Integrated Process: Teaching/Learning BLM:Cognitive Level: Remember NOT:Multiple Choice 6.The nurse is assessing risk factors on a new clinic client. These risk factors are assessed according to what?A.The individual's age B.The individual's risks C.The individual's gender D.The individual's lifestyle

ANS:B

Feedback: The nurse assesses risk factors according to the individual's risks (e.g., injury in a teenager, genetic diseases in a pregnant woman). All the remaining options have some component of the correct answer, but risk includes all those factors.PTS:1 REF:p. 968 OBJ:3 NAT:Client Needs: Health Promotion and Maintenance TOP:Chapter 30: Head-to-Toe Assessment of the Adult KEY:Integrated Process: Nursing Process BLM:Cognitive Level: Apply NOT:Multiple Choice 7.The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the nurse would be cause for concern? (Select all that apply.) A.Freckles B.Rashes C.Goose bumps D.Lesions E.Infestations

ANS:B, D, E

Feedback: The nurse inspects the skin with each corresponding body area for rashes, lesions, or infestations (such as fleas or lice). Freckles and goose bumps would not be noted as a concern.PTS:1 REF:p. 971 OBJ:6 NAT:Client Needs: Health Promotion and Maintenance TOP:Chapter 30: Head-to-Toe Assessment of the Adult KEY:Integrated Process: Nursing Process BLM:Cognitive Level: Apply NOT:Multiple Select 8.While assessing a client's eyes, the nurse notes a depressed corneal response. In what type of client would this finding be considered normal?A.A client with cataracts B.A client wearing of contact lenses C.A client with a history of macular degeneration D.A client who is blind

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