Chapter 25 Health & Physical Assessment In Nursing 3rd Edition

Chapter 25  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The nurse is caring for a client with a right femur fracture. Which type of bone does the nurse identify the femur as when discussing the fracture with the client?
1. Short.
2. Long.
3. Flat.
4. Irregular.
Correct Answer: 2
Rationale 1: Bones are classified according to shape and composition. Short bones include the carpals and tarsals.
Rationale 2: Bones are classified according to shape and composition. Long bones include the femur and humerus.
Rationale 3: Bones are classified according to shape and composition. Flat bones include the parietal skull bone and sternum.
Rationale 4: Bones are classified according to shape and composition. Irregular bones include the vertebrae and hips.
Global Rationale: Bones are classified according to shape and composition. Long bones include the femur and humerus; short bones include the carpals and tarsals; flat bones include the parietal skull bone and sternum; and irregular bones include the vertebrae and hips.
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: 25.1: Describe the anatomy and physiology of the bones, muscles, and joints.
MNL Learning Outcome: 10.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 686

Question 2
Type: MCMA
The client is recovering from orthopedic surgery on a fractured arm. When discussing the effects of the fracture with the client, which skeletal bone functions will the nurse include in the teaching session?
Standard Text: Select all that apply.
1. Provide a body framework.
2. Provide movement.
3. Maintain posture.
4. Generate heat.
5. Calcium storage.
Correct Answer: 1, 5
Rationale 1: The skeletal bones provide a framework for the body.
Rationale 2: Skeletal muscles, not bones, provide movement, maintain posture, and generate heat.
Rationale 3: Skeletal muscles, not bones, provide movement, maintain posture, and generate heat.
Rationale 4: Skeletal muscles provide movement, maintain posture, and generate heat.
Rationale 5: The skeletal bones provide a framework for the body, and they store minerals such as calcium and phosphorus.
Global Rationale: Skeletal bones provide a framework for the body and they store minerals such as calcium and phosphorus. It is the skeletal muscles that provide movement, maintain posture, and generate heat.
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: 25.1: Describe the anatomy and physiology of the bones, muscles, and joints.
MNL Learning Outcome: 10.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 686

Question 3
Type: MCSA
The nurse is providing care to a client whose chief complaint is pain in the right foot. During the physical assessment, the nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is also enlargement and inflammation noted in the area. Based on this data, which condition does the nurse suspect?
1. Flat foot.
2. Gouty arthritis.
3. Hammertoe.
4. Bunion.
Correct Answer: 4
Rationale 1: In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor.
Rationale 2: The toes are common sites for gouty arthritis. In this condition the metatarsophalangeal joint of the toe is swollen, hot, red, and extremely painful. There is no deviation of the toes.
Rationale 3: Hammertoe produces flexion of the proximal interphalangeal joint of a toe. The distal metatarsophalangeal joint hyperextends.
Rationale 4: A hallux valgus, or bunion, causes a deviation of the great toe from the midline, and crowding of the remaining toes. This crowding results in deviation. The metatarsophalangeal joint and bursa become enlarged and inflamed.
Global Rationale: A hallux valgus, or bunion, causes a deviation of the great toe from the midline, and crowding of the remaining toes. The metatarsophalangeal joint and bursa become enlarged and inflamed. In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor. In gouty arthritis the metatarsophalangeal joint of the great toe is swollen, hot, red, and extremely painful. Hammertoe produces flexion of the proximal interphalangeal joint of a toe, while the distal metatarsophalangeal joint hyperextends.
Cognitive Level: Analyzing
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: Evaluation
Learning Outcome: 25.2: Discuss the directional movements of the joints.
MNL Learning Outcome: 10.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 729

Question 4
Type: MCSA
The nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities. Which is the nurse assessing based on this description?
1. Inversion.
2. Plantar flexion.
3. Eversion.
4. Dorsiflexion.
Correct Answer: 4
Rationale 1: Inversion is the movement of pointing the sole of the foot inward.
Rationale 2: Plantar flexion is the movement of pointing the toes toward the floor.
Rationale 3: Eversion is the movement of pointing the sole of the foot outward.
Rationale 4: Dorsiflexion is the movement of pulling the toes upward toward the nose.
Global Rationale: Dorsiflexion is the movement of pulling the toes upward toward the nose. Inversion is the movement of pointing the sole of the foot inward. Plantar flexion is the movement of pointing the toes toward the floor. Eversion is the movement of pointing the sole of the foot outward.
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: 25.2: Discuss the directional movements of the joints.
MNL Learning Outcome: 10.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 730