Assessment 2nd Edition by Thompson
All Chapters Complete
, 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 hehas high blood
pressure and suffers from a leg ulcer that remains unhealed after 6 months. Whichof the following
statements would be the best choice for the nurse to use at this point in the interview?
1. I feel that you may be in denial about your health status.
2. Tell me about your definition of being healthy.
3. Do you understand what hypertension is?
4. 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 clientsviewpoint as
denial or lack of knowledge.
Rationale 2: 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, andself-expectations.
Rationale 3: The clients history of hypertension is a valid area requiring further investigation butthe nurse
must first ascertain the clients definition of healthy.
,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 hypertensionis 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 of information to the nurse.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment
Question 2 Type:
MCSA
The nurse is documenting in the clients medical record and wishes to use SOAP charting. Thenurse
includes which of the following under the assessment category?
1. The clients blood pressure was 177/93.
2. The recent loss of employment and insurance have prevented the client from being able toafford
prescription medications.
3. The client reports having lost her job and insurance 3 months ago.
, 4. Referrals have been made to social services to determine financial assistance
programsavailable.
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
thesubjective and objective data obtained.
Rationale 3: This is subjective data.
Rationale 4: This is the P component, plan.
Global Rationale: The A component of the SOAP note refers to conclusions drawn from thesubjective
and objective data obtained. The clients recent loss of employment and the potentialthat this was a
contributing factor in the inability to afford medications is an example of a conclusion. The clients 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 clients reported loss of employmentand insurance is an
example of subjective data. The statement does not include conclusions as tothe results of these events.
Making referrals to social services is an example of an intervention. Itis not a conclusion.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 3 Type:
MCSA