Chapter 13 Health & Physical Assessment In Nursing 3rd Edition

Chapter 13  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: HOTSPOT
The nurse preparing to perform a skin assessment while a student nurse observes. The student nurse asks, “Where exactly is the stratum basale located?” Which location will the nurse use to correctly identify this for the student nurse?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 1
Rationale 1: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.
Rationale 2: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.
Rationale 3: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.
Rationale 4: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.
Global Rationale: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.
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: 13.1: Identify the anatomy and physiology of the skin, hair, and nails.
MNL Learning Outcome: 6.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 212

Question 2
Type: HOTSPOT
The nurse is assessing the client’s nail. When assessing the lunula, which location does the nurse use?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 4
Rationale 1: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.
Rationale 2: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.
Rationale 3: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.
Rationale 4: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.
Global Rationale: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.
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: 13.1: Identify the anatomy and physiology of the skin, hair, and nails.
MNL Learning Outcome: 6.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 213

Question 3
Type: MCMA
The nurse is conducting a focused interview on the client’s integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders. Which question by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview?
Standard Text: Select all that apply.
1. “How much time do you spend outdoors?”
2. “How do you care for your skin?”
3. “Do you have any tattoos or body piercings?”
4. “Have you noticed any drainage from your skin?”
5. “Do you take any medications on a regular basis?”
Correct Answer: 1, 2, 3, 5
Rationale 1: The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma.
Rationale 2: The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder.
Rationale 3: Tattoos and body piercings can increase the client’s risk for developing an integumentary disorder.
Rationale 4: When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors.
Rationale 5: Certain medications, if taken on a regular basis, can increase the client’s risk for developing skin disorders.
Global Rationale: The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma. The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder. Tattoos and body piercings can increase the client’s risk for developing an integumentary disorder. Certain medications, if taken on a regular basis, can increase the client’s risk for developing skin disorders. When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.
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: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.
MNL Learning Outcome: 6.1.2. Plan questions to consider when the nurse performs a focused interview during physical assessment.
Page Number: pp. 228–231

Question 4
Type: MCSA
The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which question would be most important for the nurse to include in the interview?
1. “Do you use any skin creams?”
2. “Do you try to avoid exposure to the sun?”
3. “Have you lost any hair during your pregnancy?”
4. “Have you had any nail changes?”
Correct Answer: 1
Rationale 1: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain.
Rationale 2: Client should avoid sun exposure to prevent skin damage, but it is most important to assess the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.
Rationale 3: Losing hair during pregnancy is not necessarily as important to assess as the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.
Rationale 4: Nail changes can be assessed, but it is most important to assess the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.
Global Rationale: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.
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: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.
MNL Learning Outcome: 6.1.2. Plan questions to consider when the nurse performs a focused interview during physical assessment.
Page Number: pp. 214–215