Test Bank for Health Physical Assessment In

Test Bank for Health & Physical Assessment In Nursing, 3e Donita D'Amico, Colleen Barbarito (All Chapters)

Chapter 1

Question 1

Type: MCSA

While conducting a health history, a client states, “I am healthy, I don’t know why I have to be here to get a check-up.” However, the client reports, type 2 diabetes mellitus and an unhealed ulcer on the left foot. Based on this information, 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?”

Correct Answer: 2

Rationale 1: More information would be needed before the nurse could attribute the client’s viewpoint as denial or lack of knowledge.Rationale 2: A client will have his or her own definition of health, illness, and wellness. The individual’s concept of health and wellness is influenced by many factors, including age, gender, race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and self-expectations.Rationale 3: The client’s history of type 2 diabetes is a valid area requiring further investigation but the nurse must first ascertain the client’s definition of healthy.Rationale 4: There is not enough information to determine the client’s withholding of information to the nurse.Global Rationale: A client will have his or her own definition of health, illness, and wellness.The individual’s concept of health and wellness is influenced by many factors, including age, gender, race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and self-expectations. More information would be needed before the nurse could attribute the client’s viewpoint as denial or lack of knowledge. The client’s history of type 2 diabetes is a valid area requiring further investigation but the nurse must first ascertain the client’s definition of healthy. There is also not enough information to determine the client’s withholding of information to the nurse.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

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. 1 / 4

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: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement.Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the key components of health assessment in nursing.MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history interview of a client.

Page Number: p. 3

Question 2

Type: MCSA

Which information would the nurse include in the assessment category when using SOAP to documents in the medical record?

• The client’s blood pressure was 177/93.
• The recent loss of employment and insurance has prevented the client from being able to

afford prescription medications.

• The client reports having lost her job and insurance 3 months ago.
• Referrals have been made to social services to determine financial assistance programs

available.

Correct Answer: 2

Rationale 1: This is the “O” component; objective data.

Rationale 2: The “A” component of the SOAP note refers to conclusions drawn from the subjective and objective data obtained.

Rationale 3: This is subjective data (“S” component).

Rationale 4: This is the “P” component, plan.

Global Rationale: The “A” component of the SOAP note refers to conclusions drawn from the subjective and objective data obtained. The client’s recent loss of employment and the potential that this was a contributing factor in the inability to afford medications is an example of a conclusion. The client’s reported blood pressure would be an example of objective data.Objective data is information that can be measured by the examiner. Blood pressure is not an example of subjective information nor is it a conclusion. The client’s reported loss of employment and insurance is an example of subjective data. The statement does not include conclusions as to the results of these events. Making referrals to social services is an example of an intervention. It is not a conclusion.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement. 2 / 4

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the key components of health assessment in nursing.MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history interview of a client.

Page Number: pp. 5–8

Question 3

Type: MCSA

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 health care providers to lobby legislators for more funding.”
• “The primary goal of Healthy People 2020 is to assist health care 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.”

Correct Answer: 3

Rationale 1: Health care 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.Rationale 2: 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.Rationale 3: The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death.Rationale 4: Standards of care in disease management is not a component of the document.Global Rationale: 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. Health care 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. Standards of care in disease management are not a component of the document.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations.NLN Competencies: Knowledge and Practice: Health promotion/disease prevention.Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2: Relate the goals and objectives of Healthy People 2020 to health assessment in nursing. 3 / 4

MNL Learning Outcome:

Page Number: pp. 2–3

Question 4

Type: MCSA

The nurse is developing a handout for clients in a healthcare provider’s office. The nurse includes which focus area in this handout to emphasize current changes in the health care delivery system?

• Class recommendations for diabetics concerning insulin administration A2.Guidelines from

the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins.

• Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of

disease, eradicating the use of toxins.

• Resources available to treat chronic pain.
• Class listings for exercise classes available in the community.

Correct Answer: 4

Rationale 1: Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care.Rationale 2: Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care.Rationale 3: Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care.Rationale 4: The focus of health care in the United States today is wellness, prevention of disease, health promotion, and health maintenance, for which a listing of exercise classes is appropriate.Global Rationale: The focus of health care in the United States today is wellness, prevention of disease, health promotion, and health maintenance, for which a listing of exercise classes is appropriate. Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care. Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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: Learn cooperatively, facilitate the learning of others.Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.7: Outline the key elements of an effective teaching plan.

MNL Learning Outcome:

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