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Chapter1.UnderstandingHealthAssessment
Question1 m
f Type:MCSA
Thenurseisobtainingahealthhistoryfromaclientwhoreportsthatheishealthyandhasnohealth
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concerns.Aspartofthehealthhistory,thenursedocumentsthattheclientreportedthathehashigh
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bloodpressureandsuffersfromalegulcerthatremainsunhealedafter6months.Whichofthe
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followingstatementswouldbethebestchoiceforthenursetouseatthispointintheinterview?
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1. Ifeelthatyoumaybeindenialaboutyourhealthstatus.
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2. Tellmeaboutyourdefinitionofbeinghealthy.
3. Doyouunderstandwhathypertensionis?
4. Isthereanythingelseyouarenottellingme?
CorrectAnswer:2
Rationale1:Moreinformationwouldbeneededbeforethenursecouldattributetheclientsviewpoint
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asdenialorlackofknowledge.
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Rationale2:Aclientwill havehisorherowndefinitionofhealth,illness,andwellness.The
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individualsconceptofhealthandwellnessisinfluencedbymanyfactors,includingage,gender,
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f race,family,culture,religion,socioeconomicconditions,environment,previousexperiences,and
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f self-expectations.
Rationale3:Theclientshistoryofhypertensionisavalidarearequiringfurtherinvestigationbutthe
nursemustfirstascertaintheclientsdefinitionofhealthy.
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,Rationale4:Thereisnote v fv
m m noughinformationtodeterminetheclientswithholdingofinformation
f tothenurse.
GlobalRationale:Aclientwillhavehisorherowndefinitionofhealth,illness,andwellness.The
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individualsconceptofhealthandwellnessisinfluencedbymanyfactors,includingage,gender,race,
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f family,culture,religion,socioeconomicconditions,environment,previousexperiences,andself-
expectations.Moreinformationwouldbeneededbeforethenursecouldattributetheclients
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viewpointasdenialorlackofknowledge.Theclientshistoryofhypertensionisavalidarearequiring
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furtherinvestigationbutthenursemustfirstascertaintheclientsdefinitionofhealthy.Thereisalso
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notenoughinformationtodeterminetheclientswithholdingofinformationtothenurse.
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CognitiveLevel:Analyzing
Client N eed:HealthPromotionandMaintenance
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ClientNeedSub:
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Nursing/IntegratedConcepts:NursingProcess:Assessment
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LearningOutcome:1.4:Identifythefactorstoconsiderinhealthassessment v
f Question2
Type:MCSA
ThenurseisdocumentingintheclientsmedicalrecordandwishestouseSOAPcharting.Thenurse
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f includeswhichofthefollowingundertheassessmentcategory?
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1. Theclientsbloodpressurewas177/93. v
2. Therecentlossofemploymentandinsurancehavepreventedtheclientfrombeing ableto v
f affordprescriptionmedications.
3. Theclient reports havinglostherjobandinsurance3monthsago.
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,4. Referralshavebeenmadetosocialservicestodeterminefinancialassistanceprograms
available.
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CorrectAnswer:2
Rationale1:ThisistheOcomponent,objectivedata.
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Rationale2:TheAcomponentoftheSOAPnotereferstoconclusionsdrawnfromthesubjective
f andobjectivedataobtained.
Rationale3:Thisissubjectivedata.
Rationale4:ThisisthePcomponent,plan.
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GlobalRationale:TheAcomponentoftheSOAPnotereferstoconclusionsdrawnfromthe
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f subjectiveandobjectivedataobtained.Theclientsrecentlossofemploymentandthep
v v mv mv otentialthat
f thiswasacontributingfactorintheinabilitytoaffordmedicationsisanexampleofaconclusion.The
f clientsreportedbloodpressurewouldbeanexampleofobjectivedata.
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Objectivedataisinformationthatcanbemeasuredbytheexaminer.Bloodpressurei snotan
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f exampleofsubjectiveinformationnorisitaconclusion.Theclientsreportedlossofemploymentand
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f insuranceisanexampleofsubjectivedata.Thestatementdoesnotincludeconclusionsastotheresults
f oftheseevents.Makingreferralstosocialservicesisanexampleofanintervention.Itisnota
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f conclusion.
CognitiveLevel:Applying
ClientNeed:HealthPromotionandMaintenance
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ClientNeedSub:
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Nursing/IntegratedConcepts:NursingProcess:Assessment
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LearningOutcome:1.4:Identifythefactorstoconsiderinhealthassessment.v
Question3
Type:MCSA
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, The nurse is presenting a workshop on wellness and health promotion and the initiatives of
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f Healthy People 2020 as a resource for this topic. After the session, which of the following
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f statementsbyaparticipantindicatesanunderstandingconcerningtheinitiativesproposed?
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1. Itwillallowhealthcareproviderstolobbylegislatorsformorefunding. v
2. TheprimarygoalofHealthyPeople2020istoassisthealthcareprovidersindeterminingrisk
f factorsforprematurebirth.
3. HealthyPeople2020seekstopromoteshealth,preventillness,disability,andprematuredeath. v
4. Theinitiatives willoutlinestandardsofcareforprovidersinmanagingdiseases.
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CorrectAnswer:3
Rationale1:Healthcareprovidersandotherpersonsinterestedinprogramstopromotehealthhave
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foundthedocumenttobeausefulsourceofinformationintheireffortstogainfunding.
Rationale2:TheHealthyPeople2020initiativeisa10-yearstrategyintendedtopromotehealth,
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preventillness,disability,andprematuredeath.Thedocumentidentifiesleadinghealthindicators that
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reflectpublichealthconcerns.Riskfactorsforprematurebirthmaybepartof those health
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f indicators,butthescopeofthedocumentcoversbroadareasofconcern. v
Rationale3:TheHealthyPeople2020initiativeisa10-yearstrategyintendedtopromotehealth,prevent
illness,disability,andprematuredeath.
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Rationale4:Standardsofcareindiseasemanagementisnotacomponentofthedocument.
GlobalRationale:TheHealthyPeople2020initiativeisa10-yearstrategyintendedtopromote
health,preventillness,disability,andprematuredeath.Thedocumentidentifiesleadinghealth
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indicatorsthatreflectpublichealthconcerns.Riskfactorsforprematurebirthmaybepartofthose
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healthindicators,butthescopeofthedocumentcoversbroadareasofconcern.Healthcareproviders
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andotherpersonsinterestedinprogramstopromotehealthhavefoundthedocumenttobeauseful
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sourceofinformationintheireffortstogainfunding.Standardsofcareindiseasemanagementisnota
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f componentofthedocument. v