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