Health and Physical Assessment In Nursing 3rd Edition DAmico Test Bank Chapter 1 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?
- “I feel that you may be in denial about your health status.”
- “Tell me about your definition of being healthy.”
- “Do you understand what hypertension is?”
- “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 client’s viewpoint as denial or lack of knowledge.
Rationale 2: A client will have his or her own definition of health, illness, and wellness. The individual’s 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.
Rationale 3: The client’s history of hypertension is a valid area requiring further investigation but the nurse must first ascertain the client’s definition of healthy.
Rationale 4: There is not enough information to determine the client’s withholding of information to the nurse.
Global Rationale: A client will have his or her own definition of health, illness, and wellness. The individual’s 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 client’s viewpoint as denial or lack of knowledge. The client’s history of hypertension is a valid area requiring further investigation but the nurse must first ascertain the client’s definition of healthy. There is also not enough information to determine the client’s 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 1 / 4
Question 2
Type: MCSA
The nurse is documenting in the client’s medical record and wishes to use SOAP charting. The nurse includes which of the following under the assessment category?
- The client’s blood pressure was 177/93.
- The recent loss of employment and insurance have prevented the client from being able to afford prescription
medications.
- The client reports having lost her job and insurance 3 months ago.
- Referrals have been made to social services to determine financial assistance programs available.
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 the subjective 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 the subjective and objective data obtained. The client’s recent loss of employment and the potential that this was a contributing factor in the inability to afford medications is an example of a conclusion. The client’s 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 client’s reported loss of employment and insurance is an example of subjective data. The statement does not include conclusions as to the results of these events. Making referrals to social services is an example of an intervention. It is 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
The nurse is presenting a workshop on wellness and health promotion and the initiatives of Healthy People 2020 as a resource for this topic. After the session, which of the following statements by a participant indicates an understanding concerning the initiatives proposed?
- “It will allow health care providers to lobby legislators for more funding.” 2 / 4
- “The primary goal of Healthy People 2020 is to assist health care providers in determining risk factors for
premature birth.”
- “Healthy People 2020 seeks to promotes health, prevent illness, disability, and premature death.”
- “The initiatives will outline standards of care for providers in managing diseases.”
Correct Answer: 3
Rationale 1: Health care 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.
Rationale 2: The Healthy People 2020 initiative is a 10-year strategy 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.
Rationale 3: The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death.
Rationale 4: Standards of care in disease management is not a component of the document.
Global Rationale: The Healthy People 2020 initiative is a 10-year strategy 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. Health care 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. Standards of care in disease management is not a component of the document.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2: Discuss the importance of Healthy People 2020 and its relevance to health assessment.
Question 4
Type: MCSA
The nurse is developing a handout for clients in a healthcare provider’s office. The nurse would include which of the following focus areas in this handout to emphasize current changes in the health care delivery system?
- Class recommendations for diabetics concerning insulin administration A2.Guidelines from the Centers for
Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins
- Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the
use of toxins
- Resources available to treat chronic pain 3 / 4
- Class listings for exercise classes available in the community
Correct Answer: 4
Rationale 1: Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care.
Rationale 2: Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care.
Rationale 3: Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care.
Rationale 4: The focus of health care in the United States today is wellness, prevention of disease, health promotion and health maintenance, for which a listing of exercise classes is appropriate.
Global Rationale: The focus of health care in the United States today is wellness, prevention of disease, health promotion, and health maintenance, for which a listing of exercise classes is appropriate. Symptom management, illness care, and pain management are addressed by the health care delivery system but are not the primary focus, as clients are taking a more active role in managing their own care. Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.8: Discuss the elements of a teaching plan.
Question 5
Type: MCSA
The nurse is admitting a client to the acute care facility. The health history form has a place for recording subjective data. The nurse understands that primary subjective data should be obtained from which of the following sources?
- The client’s physical assessment
- The client’s self-reports
- The client’s healthcare provider
- The client’s significant other
Correct Answer: 2
Rationale 1: The physical assessment will be recorded as objective data.
- / 4