Chapter 17 Health & Physical Assessment In Nursing 3rd Edition

Chapter 17  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: HOTSPOT
The client aspirated a pea during a meal. The healthcare provider notes that the pea is located in the bronchus. When educating the client regarding the location of the pea, which is the correct location for the nurse to use?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 1
Rationale 1: The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung.
Rationale 2: The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung.
Rationale 3: The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung.
Rationale 4: The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung.
Global Rationale: The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
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: 17.1: Describe the anatomy and physiology of the respiratory system.
MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 372

Question 2
Type: MCSA
The nurse is examining a client who is diagnosed with a fracture of one floating rib. Of the following ribs, which does the nurse suspect to be fractured?
1. 1.
2. 5.
3. 9.
4. 12.
Correct Answer: 4
Rationale 1: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.
Rationale 2: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.
Rationale 3: The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7.
Rationale 4: The rib pairs of 11 and 12 are free floating and do not articulate anteriorly.
Global Rationale: The 12 pairs of ribs circle the body, form the lateral aspects of the thorax, and are attached to the vertebrae and sternum. Anteriorly, the first seven pairs of ribs articulate directly to the sternum. The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7, whereas the pairs of 11 and 12 are free floating and do not articulate anteriorly.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
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: 17.1: Describe the anatomy and physiology of the respiratory system.
MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 375

Question 3
Type: HOTSPOT
The nurse is conducting an assessment. Where is the right anterior axillary line (ALL) located?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 1
Rationale 1: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.
Rationale 2: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.
Rationale 3: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.
Rationale 4: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.
Global Rationale: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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: 17.2: Identify landmarks that guide assessment of the respiratory system.
MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 378

Question 4
Type: MCSA
The nurse wants to assess the apex of a client’s right lung. Which locations should the nurse place the stethoscope to assess this area on the client?
1. Intercostal space sixth rib near the sternum.
2. Intercostal space fourth rib near the axillary line.
3. Below the scapula.
4. Near the right clavicle.
Correct Answer: 4
Rationale 1: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 2: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 3: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 4: The apex of each lung is slightly superior to the inner third of the clavicle.
Global Rationale: The apex of each lung is slightly superior to the inner third of the clavicle whereas the base of each lung rests on the diaphragm.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
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: 17.2: Identify landmarks that guide assessment of the respiratory system.
MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 373