Chapter 22 Health & Physical Assessment In Nursing 3rd Edition

Chapter 22  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The nurse is interviewing an older adult client in the clinic who reports incontinence. Numerous attempts in the recent past have been unsuccessful in helping to control the problem. Which is the priority diagnosis for this client?
1. Skin integrity impairment.
2. Self-care deficit.
3. Self-esteem, situational-low.
4. Infection.
Correct Answer: 3
Rationale 1: Skin integrity impairment is of concern, but there is no data in this scenario to indicate that it is the highest priority nursing diagnosis.
Rationale 2: There is no data in this situation to indicate any self-care deficit issues.
Rationale 3: Since the client has had no success in controlling the incontinence after repeated attempts, this client is at a high risk for situational low self-esteem.
Rationale 4: There is no data in this scenario to indicate a risk for infection.
Global Rationale: Clients suffering from incontinence are at increased risk for social isolation, self-esteem disturbance, and other psychosocial problems. There is no data to support a self-care deficit; the information available is that this client has tried to implement measures to treat the problem. The client is certainly at risk for infection and skin integrity impairment, but these two are not active at this time.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
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: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.
MNL Learning Outcome: 13.1.3; 14.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.
Page Number: p. 581

Question 2
Type: MCMA
The nurse is interviewing a client regarding urinary health. Which response would the nurse include during the collection of subjective data?
Standard Text: Select all that apply.
1. “Do you have difficulty starting your stream of urine?”
2. “After you urinate, does your bladder feel full or empty?”
3. “Do you ever have an accident or wet yourself when you sneeze?”
4. “Do you have to hurry to the bathroom when you have to urinate?”
5. “Your recent urinalysis reveals protein in the urine.”
Correct Answer: 1, 2, 3, 4
Rationale 1: Difficulty starting a stream usually indicates prostate disease in the male client.
Rationale 2: Urinary retention, or holding residual urine in the bladder after voiding, creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection.
Rationale 3: Stress incontinence is most likely the cause of the client experiencing partial or complete incontinence when sneezing, coughing, and laughing due to loss of muscle control.
Rationale 4: Urge incontinence is most likely the cause of the client experiencing partial or complete incontinence if the client is consistently unable to reach the bathroom in time, and is due to loss of muscle control.
Rationale 5: This is an example of objective data, not subjective data.
Global Rationale: Urinary retention or holding residual urine in the bladder after voiding creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection. Difficulty starting a stream usually indicates prostate disease in the male client. Stress incontinence and urgency occur when there is loss of muscle control over urination. Telling the client the results of the recent urinalysis is an example of objective data.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
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: 22.3: Develop questions to be used when completing the focused interview.
MNL Learning Outcome: 13.1.2; 14.1.2. Plan questions to consider when the nurse performs a focused interview during physical assessment.
Page Number: p. 582

Question 3
Type: MCSA
The nurse is collecting a urine specimen from a client and notes the urine is foamy and amber in color. Based on this data, which diagnosis would the nurse suspect?
1. Kidney stones.
2. Urinary tract infection.
3. Prostate disease.
4. Liver disease.
Correct Answer: 4
Rationale 1: Pain is the primary symptom for the client with kidney stones. The pain may radiate and is variable in location and severity. Other symptoms include spasms, nausea, vomiting, pain on urination, frequency and urgency of urination, and gross hematuria.
Rationale 2: If a urinary tract infection is present, the client may complain of pain during urination with urgency, frequency, dribbling, pain upon urination, and suprapubic or lower back pain. Hematuria, as well as cloudy and foul-smelling urine may also accompany a urinary tract infection.
Rationale 3: Prostate disease may make it difficult for male clients to begin or maintain their urine stream.
Rationale 4: Foamy, amber-colored urine frequently is an indication of hepatic illness (liver disease).
Global Rationale: Foamy, amber-colored urine may indicate the presence of hepatic illness (liver disease). Pain is the primary symptom for the client with kidney stones. The pain may radiate and is variable in location and severity. Other symptoms include spasms, nausea, vomiting, pain on urination, frequency and urgency of urination, and gross hematuria. If a urinary tract infection is present, the client may complain of pain during urination with urgency, frequency, dribbling, pain upon urination, and suprapubic or lower back pain. Hematuria, as well as cloudy and foul-smelling urine may also accompany a urinary tract infection. Prostate disease may make it difficult for male clients to begin or maintain their urine stream.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.
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: Evaluation
Learning Outcome: 22.6: Differentiate normal from abnormal findings in physical assessment of the urinary system.
MNL Learning Outcome: 13.2.1; 14.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.
Page Number: p. 600

Question 4
Type: MCSA
The nurse is caring for an infant with newly diagnosed renal disease. Diagnostic tests for which system is the priority for this infant?
1. Ears.
2. Heart.
3. Lungs.
4. Joints.
Correct Answer: 1
Rationale 1: The ears and kidneys develop at the same time in utero. Congenital deafness is frequently associated with renal disease; therefore, the auditory function of the baby with known renal disease would be important to assess because of the embryonic development.
Rationale 2: Even though all body systems should be assessed to make sure their function is normal, the heart would not be the highest priority system since congenital deafness is frequently associated with renal disease due to the ears and kidneys developing at the same time in utero.
Rationale 3: Even though all body systems should be assessed to make sure their function is normal, the lungs would not be the highest priority system since congenital deafness is frequently associated with renal disease due to the ears and kidneys developing at the same time in utero.
Rationale 4: Even though all body systems should be assessed to make sure their function is normal, the joints would not be the highest priority system since congenital deafness is frequently associated with renal disease due to the ears and kidneys developing at the same time in utero.
Global Rationale: The ears and kidneys develop at the same time in utero. Congenital deafness is associated with renal disease. Even though all other systems would be assessed to make sure their function is normal, the auditory function of the baby with known renal disease would be important to assess because of the embryonic development.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
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: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.
MNL Learning Outcome: 13.1.3; 14.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.
Page Number: p. 589

Question 5
Type: MCSA
The nurse is admitting a client with constant, severe flank pain, spasms, nausea and vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the low back to the lower quadrants of the abdomen. Which nursing action is the priority for this client?
1. Administer pain medication.
2. Notify the healthcare provider immediately.
3. Obtain a urine specimen for culture.
4. Complete the assessment.
Correct Answer: 2
Rationale 1: Administering pain medication would not be appropriate since the client’s symptoms indicate hydroureter.
Rationale 2: Hydroureter is a complication that occurs when a renal calculus (kidney stone) moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea and vomiting, and diminished volume of urine (oliguria). Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function; therefore, the healthcare provider should be notified immediately.
Rationale 3: Obtaining a urine specimen for culture would not be appropriate since the client’s symptoms indicate hydroureter.
Rationale 4: Completing the assessment would not be appropriate since the client’s symptoms indicate hydroureter.
Global Rationale: Hydroureter is a complication that occurs when a renal calculus moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea and vomiting, and diminished volume of urine (oliguria). Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function, and medical collaboration should be initiated immediately. All other options would not be appropriate in an emergency situation.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.
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: 22.6: Differentiate normal from abnormal findings in physical assessment of the urinary system.
MNL Learning Outcome: 13.2.1; 14.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.
Page Number: p. 597