Chapter 21 Health & Physical Assessment In Nursing 3rd Edition

Chapter 21  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: HOTSPOT
The nurse is preparing to perform an abdominal assessment. The client states, “Can you point to where my appendix is located?” Which location will the nurse point to when answering this client’s question?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 4
Rationale 1: The vermiform appendix is attached to the large intestines at the cecum.
Rationale 2: The vermiform appendix is attached to the large intestines at the cecum.
Rationale 3: The vermiform appendix is attached to the large intestines at the cecum.
Rationale 4: The vermiform appendix is attached to the large intestines at the cecum.
Global Rationale: The vermiform appendix is attached to the large intestines at the cecum.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 12.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 535

Question 2
Type: HOTSPOT
The nurse is speaking with the client during the focused interview. The client states, “My doctor said that my spleen was enlarged. Where is my spleen?” Which location will the nurse point to when answering this client’s question?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 2
Rationale 1: The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm.
Rationale 2: The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm.
Rationale 3: The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm.
Rationale 4: The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm.
Global Rationale: The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 12.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 535

Question 3
Type: MCMA
A client asks the nurse, “What’s the purpose of the liver?” Which statements will the nurse include in the response to this client’s question?
Standard Text: Select all that apply.
1. “It helps you digest fats.”
2. “It is an endocrine and exocrine gland.”
3. “It filters waste from the blood and makes urine.”
4. “It makes some blood-clotting substances.”
5. “It can help you store certain vitamins.”
Correct Answer: 1, 4, 5
Rationale 1: The liver helps the body digest fats by producing bile.
Rationale 2: The pancreas is an example of an exocrine and endocrine gland.
Rationale 3: The kidneys filter nitrogen waste from the blood and make urine.
Rationale 4: The liver makes blood-clotting substances.
Rationale 5: The liver can store certain types of vitamins.
Global Rationale: The liver produces and secretes bile for fat breakdown, but also aids in the metabolism of proteins and carbohydrates. It stores some vitamins, helps with blood coagulation, produces antibodies, and detoxifies some harmful substances. The pancreas is an example of an exocrine and endocrine gland. The kidneys filter nitrogen waste from the blood and make urine.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 12.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: pp. 534–535

Question 4
Type: MCMA
The nurse is palpating the right upper quadrant of a client’s abdomen. Which organs may be assessed during this portion of the assessment?
Standard Text: Select all that apply.
1. Liver.
2. Gallbladder.
3. Appendix.
4. Spleen.
5. Stomach.
Correct Answer: 1, 2
Rationale 1: The liver is located in the right upper quadrant.
Rationale 2: The gallbladder is located in the right upper quadrant.
Rationale 3: The appendix is located in the right lower quadrant.
Rationale 4: The spleen is located in the left upper quadrant.
Rationale 5: The stomach is located in the left upper quadrant.
Global Rationale: The liver and gallbladder are located in the right upper quadrant. The appendix is located in the right lower quadrant. The spleen and stomach are located in the left upper quadrant.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 12.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 535

Question 5
Type: MCSA
A client asks the nurse, “What’s the purpose of a gall bladder anyway? My mom lived for many years without her gallbladder.” Which information would be beneficial for the nurse to share with this client?
1. “You are right. We still don’t know the function of the gallbladder.”
2. “It stores bile until it is needed for digestion of fats.”
3. “It destroys old red blood cells.”
4. “It helps you digest carbohydrates by producing enzymes.”
Correct Answer: 2
Rationale 1: The gallbladder does have an important function within the body.
Rationale 2: The gallbladder is used to store bile that is produced in the liver, until the bile is needed to help digest fats.
Rationale 3: The spleen destroys red blood cells.
Rationale 4: The pancreas helps the body digest carbohydrates.
Global Rationale: The gallbladder is used to store bile. It is a thin-walled sac that is nestled in a shallow depression on the ventral surface of the liver. The gallbladder releases stored bile into the duodenum when stimulated and thus promotes the emulsification of fats. The main functions of the gallbladder are storing of bile and assisting in the digestion of fats. The spleen destroys red blood cells. The pancreas helps the body digest carbohydrates.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 12.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 535