Chapter 24 Health & Physical Assessment In Nursing 3rd Edition

Chapter 24  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: HOTSPOT
An adolescent client has been brought to the clinic with complaints of pain. After an examination it is determined that the client has an inflamed Bartholin’s cyst. The client and her mother ask the nurse to show them the location of the gland involved. Which location does the nurse show the client and her mother?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 3
Rationale: The Bartholin’s glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule.
Global Rationale: The Bartholin’s glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule.
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: 24.1: Describe the anatomy and physiology of the female reproductive system.
MNL Learning Outcome: 13.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 644

Question 2
Type: HOTSPOT
The nurse is caring for a pregnant client. The nurse notes the healthcare provider has documented the client has a positive Goodell’s sign. Where is Goodell sign located?

1. A.
2. B.
3. C.
4. D.
Correct Answer: 3
Rationale: Goodell’s sign refers to the softening of the cervix during pregnancy.
Global Rationale: Goodell’s sign refers to the softening of the cervix during pregnancy.
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: Assessment
Learning Outcome: 24.1: Describe the anatomy and physiology of the female reproductive system.
MNL Learning Outcome: 13.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 648

Question 3
Type: MCMA
The nurse is preparing to assess a female client’s external genitalia. Which structures will the nurse include in this assessment?
Standard Text: Select all that apply.
1. Vagina.
2. Cervix.
3. Clitoris.
4. Labia majora.
5. Labia minora.
Correct Answer: 3, 4, 5
Rationale 1: The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries.
Rationale 2: The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries.
Rationale 3: Female external genitalia include the mons pubis, labia majora, labia minora, glands, clitoris, and perianal area.
Rationale 4: Female external genitalia include the mons pubis, labia majora, labia minora, glands, clitoris, and perianal area.
Rationale 5: Female external genitalia include the mons pubis, labia majora, labia minora, glands, clitoris, and perianal area.
Global Rationale: The female external genitalia include the clitoris, labia majora, and the labia minora. The vagina and cervix are considered to be internal genitalia.
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: Assessment
Learning Outcome: 24.1: Describe the anatomy and physiology of the female reproductive system.
MNL Learning Outcome: 13.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: pp. 644–645

Question 4
Type: MCSA
The nurse notes a forward-tilted uterus with a downward-tilted cervix when examining a female client. Which term will the nurse use to document this finding in the medical record?
1. Anteflexion.
2. Retroversion.
3. Anteversion.
4. Midposition.
Correct Answer: 3
Rationale 1: The uterus in anteflexion is folded forward at a 90-degree angle with the cervix is tilted downward.
Rationale 2: The retroversion uterus is tilted backward with the cervix tilted upward.
Rationale 3: Normal variations of uterine position include anteversion in which the uterus is tilted forward, the cervix is tilted downward.
Rationale 4: The uterus in midposition lies parallel to the tailbone with the cervix pointed straight.
Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted upward). Abnormal variations of uterine position include anteflexion (the uterus is folded forward at a 90-degree angle, the cervix is tilted downward).
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: 24.1: Describe the anatomy and physiology of the female reproductive system.
MNL Learning Outcome: 13.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 647

Question 5
Type: MCSA
The nurse notes that the uterus is folded backward at a 90-degree angle with the cervix tilted upward when examining a female client. Which term will the nurse use to document this finding in the medical record?
1. Retroversion.
2. Retroflexion.
3. Midposition.
4. Anteversion.
Correct Answer: 2
Rationale 1: The retroversion positioned uterus is tilted backward with the cervix tilted upward.
Rationale 2: The retroflexion uterus is folded backward at a 90-degree angle with the cervix tilted upward.
Rationale 3: The midposition uterus lies parallel to the tailbone, the cervix is pointed straight.
Rationale 4: The anteversion uterus is tilted forward with the cervix tilted downward.
Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted upward). Abnormal variations of uterine position include retroflexion (the uterus is folded backward at a 90-degree angle, the cervix is tilted upward).
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: 24.1: Describe the anatomy and physiology of the female reproductive system.
MNL Learning Outcome: 13.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 674