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, Essential Health Assessment 2nd Edition Thompson Test Bank
Chapter 1. Understanding Health Assessment
Question 1
Type: MCSA
The nurse is obtaining a health history from a client who reports that he is healthy and has no
health concerns. As part of the health history, the nurse documents that the client reported that he
has high blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. Which
of the following statements would be the best choice for the nurse to use at this point in the
interview?
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1. I feel that you may be in denial about your health status.
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2. Tell me about your definition of being healthy.
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3. Do you understand what hypertension is? tp
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4. Is there anything else you are not telling me?
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Correct Answer: 2
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Rationale 1: More information would be needed before the nurse could attribute the clients
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viewpoint as denial or lack of knowledge.
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Rationale 2: A client will have his or her own definition of health, illness, and wellness. The
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individuals concept of health and wellness is influenced by many factors, including age, gender,
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race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and
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self-expectations.
Rationale 3: The clients history of hypertension is a valid area requiring further investigation but
the nurse must first ascertain the clients definition of healthy.
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, Rationale 4: There is not enough information to determine the clients withholding of
information to the nurse.
Global Rationale: A client will have his or her own definition of health, illness, and wellness.
The individuals 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 clients viewpoint as denial or lack of knowledge. The clients history of hypertension
is a valid area requiring further investigation but the nurse must first ascertain the clients
definition of healthy. There is also not enough information to determine the clients withholding
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of information to the nurse.
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Cognitive Level: Analyzing
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 1.4: Identify the factors to consider in health assessment
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Question 2
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Type: MCSA
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The nurse is documenting in the clients medical record and wishes to use SOAP charting. The
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nurse includes which of the following under the assessment category?
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1. The clients blood pressure was 177/93.
2. The recent loss of employment and insurance have prevented the client from being able to
afford prescription medications.
3. The client reports having lost her job and insurance 3 months ago.
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