TEST BANK FOR HEALTH AND PHYSICAL ASSESSMENT INNURSING, 4THEDITION, CYNTHIA FENSKE , KATHERINE DOLAN WATKINS, TINA SAUNDERS, DONITA D’ AMICO, COLLEENBARBARITO

TEST BANK FOR HEALTH AND PHYSICAL ASSESSMENT INNURSING, 4THEDITION, CYNTHIA FENSKE , KATHERINE DOLAN WATKINS, TINA SAUNDERS, DONITA D’ AMICO, COLLEENBARBARITO Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 1 Health Assessment Table of Contents UNIT I: FOUNDATIONS OF HEALTH ASSESSMENT 1. Health Assessment 2. Health and Wellness 3. Cultural and Spiritual Considerations 4. Health Disparities UNIT II: TECHNIQUES FOR HEALTH ASSESSMENT 5. Interviewing and Health History: Subjective Data 6. Documentation 7. Physical Assessment Techniques and Equipment 8. General Survey and Physical Exam: Objective Data 9. Pain Assessment 10. Nutritional Assessment 11. Psychosocial Health, Substance Use, and Violence Assessment UNIT III: PHYSICAL ASSESSMENT 12. Skin, Hair, and Nails 13. Head, Neck, and Related Lymphatics 14. Eyes 15. Ears, Nose, Mouth, and Throat 16. Lungs and Thorax 17. Breasts and Axillae 18. Cardiovascular System 19. Peripheral Vascular System 20. Abdomen 21. Male Genitourinary System 22. Female Genitourinary System 23. Musculoskeletal System 24. Neurologic System UNIT IV: SPECIALIZED ASSESSMENT 25. Pregnant Woman 26. Infants, Children, and Adolescents 27. Older Adult 28. Complete Health Assessment Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 1 Health Assessment 1) A client with a self-reported history of type 2 diabetes mellitus and an ulcer wound on the left foot states to the nurse, "I am healthy, I don't know why I have to be here to get a check-up." Which statement by the nurse is the most appropriate? 1. "I feel that you are in denial about your health status." 2. "Tell me about your definition of being healthy." 3. "Do you understand what diabetes is?" 4. "Is there anything else you are not telling me?" Answer: 2 Explanation: 1. More information would be needed before the nurse could attribute the client's viewpoint as denial or lack of knowledge. 2. During the process of gathering the subjective data from the client, the nurse must be attuned to what the patient says, along with the signs, symptoms, behaviors, and cues offered by the patient. This situational awareness and focused data collection will enable the nurse to create a comprehensive database about the patient. 3. The client's history of type 2 diabetes requires further investigation but the nurse must first ascertain the client's definition of what healthy means. 4. There is not enough information to determine the client's withholding of information to the nurse. Page Ref: 4 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Illness Management Standards: 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: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing. 2) The nurse is preparing to provide teaching to a client at risk for diabetes. During which time should the nurse recognize is the most effective moment for teaching? 1. During health promotion. 2. When the client is ready to learn. 3. During the discussion of disease prevention. 4. When a knowledge deficit has been identified. Answer: 2 Explanation: 1. Health promotion is important; however, if the client is not ready to learn new information, the teaching may be ineffective. 2. A client must be ready to learn new information or the teaching may be ineffective. 3. Disease prevention is important; however, if the client is not ready to learn new information, the teaching may be ineffective. 4. Once the knowledge deficit is identified, it is important that client is ready to learn or the teaching may be ineffective. Page Ref: 2 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: 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: Factors that contribute to or threaten health; communicate information effectively; and listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare. 3) 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? 1. "It will allow healthcare providers to lobby legislators for more funding." 2. "The primary goal of Healthy People 2020 is to assist healthcare providers in determining risk factors for premature birth." 3. "Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death." 4. "The initiatives will outline standards of care for providers in managing diseases." Answer: 3 Explanation: 1. Healthcare 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. 2. The Healthy People 2020 initiative is a 10-yearstrategy 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. 3. The Healthy People 2020 initiative is a 10-yearstrategy intended to promote health, prevent illness, disability, and premature death. 4. Standards of care in disease management is not a component of the document. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care; patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.6: Describe the concepts of health, wellness, and health disparities. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing. 4) The nurse is reviewing the advanced practice roles in nursing. Which role should the nurse recognize is most likely to provide indirect patient care? 1. Nurse Researcher. 2. Nurse Administrator. 3. Nurse Educator. 4. Nurse Anesthetist. Answer: 2 Explanation: 1. A nurse researcher may provide direct care through their work in a clinic, hospital, or laboratory focusing on patient care outcomes, administering treatments for clinical trial, or collecting data to help understand population based outcomes. 2. The nurse administrator does not provide direct patient care but may be utilized for consultation. Other responsibilities vary and could include management of complex patient care areas, staffing, budgets, organizational and staff performance, and ensuring that the goals of the agency are being accomplished. 3. The nurse educator isresponsible for didactic and clinical teaching, curriculum development, clinical placement, and evaluation of learning. Direct patient care occurs during clinical teaching. 4. The nurse anesthetist has direct patient care by providing a full range of anesthesia services. Page Ref: 2 Cognitive Level: Applying Client Need & Sub: Management of Care; Concepts of Management Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals; function competently within one's own scope of practice as leader or member of the healthcare team; and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare. MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare. 5) The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which source should the nurse use? 1. The client's physical assessment. 2. The client'sself-reports. 3. The client's healthcare provider. 4. The client'ssignificant other. Answer: 2 Explanation: 1. The physical assessment will be recorded as objective data. 2. Subjective data are gathered from the interview. The interview includes the health history and focused interview of the patient which is considered primary subjective data. 3. The client's healthcare provider and significant other may contribute in the data collection process. The information obtained from friends and family members is considered subjective. This source of information is termed secondary. 4. The client's significant other may contribute in the data collection process but that input is classified as secondary data. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: 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: Relationship Centered Care: Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2: Explain evidence-based practice and its significance in nursing. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking. 6) The nurse is reviewing a client's medical records. Which should the nurse recognize as subjective data? 1. The client tells the nurse their abdomen hurts on the left side after eating. 2. The client's abdomen istender on the left side during palpation. 3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen. 4. The client's hemoglobin is 14.1 gm/dL. Answer: 1 Explanation: 1. Subjective reports by the client are those feelings or symptoms that cannot be observed by others. The statement "My abdomen hurts," is subjective data. 2. Physical examination findings, radiographic findings, and laboratory analysis reports are objective data. 3. Physical examination findings, radiographic findings, and laboratory analysis reports are objective data. 4. Physical examination findings, radiographic findings, and laboratory analysis reports are objective data. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: 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 and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.4: Examine the components of health assessment. 7) The nurse is reviewing a client's medical record. Which documented data should the nurse recognize is objective? 1. The client states, "fell and hurt myself." 2. The client states, "I am six years old." 3. "Six-year-old child observed holding a towel to her forehead." 4. "Client states that she was running and fell at the playground." Answer: 3 Explanation: 1. Statements the client makes are subjective data. 2. Statementsthe client makes are subjective data. 3. Objective data are data that can be observed or measured by the nurse. The nurse can see the child holding the towel to her head. 4. Statementsthe client makes are subjective data. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: 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. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.4: Examine the components of health assessment. 8) The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action should the nurse take? 1. Report the lack of achievement of the goalsto the healthcare provider. 2. Review the data and modify the plan. 3. Reformulate the nursing diagnosisto a more realistic one. 4. Request a consult for the client to be seen by a pulmonologist. Answer: 2 Explanation: 1. Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be. 2. The plan of care should be evaluated periodically at established time frames to determine achievement of the goals. If goals have not been achieved, revisions should be made which may include adding, changing, or discontinuing nursing diagnoses or nursing interventions. 3. Reformulating the nursing diagnosis to a more realistic one is not the best course of action, as the diagnosis established came from subjective and objective data specific to that diagnosis. 4. There is no data to support the need for additional medical consultations. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Illness Management Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.