Chapter 29 Health & Physical Assessment In Nursing 3rd Edition

Chapter 29  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCMA
The nurse is preparing to perform an interview to obtain information about the client. Which are classified as secondary sources of information?
Standard Text: Select all that apply.
1. The client’s wife.
2. The client’s medical record from his last hospital admission.
3. The client.
4. The client’s daughter.
5. The client’s physical therapist.
Correct Answer: 1, 2, 4, 5
Rationale 1: The client’s wife is an example of a secondary source of information.
Rationale 2: The client’s medical record is an example of a secondary source of information.
Rationale 3: The client is the primary source of information.
Rationale 4: The client’s daughter is an example of a secondary source of information.
Rationale 5: The client’s physical therapist is another member of the client’s health team and is a secondary source of information.
Global Rationale: The client’s wife, daughter, physical therapist, and medical record are all examples of secondary source of information. The client is the primary source of information.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.9. Discuss principles of effective communication.
AACN Essentials Competencies: VII.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care.
NLN Competencies: Relationship Centered Care: Communicate information effectively; Listen openly and cooperatively.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 29.1: Use professional communication skills to gather subjective data in a health history.
MNL Learning Outcome:
Page Number: p. 862

Question 2
Type: MCMA
The nurse is interviewing the client. Which interaction could lead to a communication breakdown between the nurse and client?
Standard Text: Select all that apply.
1. The client is a Native American and the nurse is of Northern European descent.
2. During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day.
3. The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client.
4. The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client.
5. The nurse states, “So, you experience pain with micturition.”
Correct Answer: 1, 2, 5
Rationale 1: Communication has an increased chance of breaking down when the nurse and the client are from different cultures. Some Native Americans believe that direct eye contact is an invasion of privacy and a firm handshake can be an aggressive action. A person of Northern European descent may feel that a person who avoids direct eye contact is untrustworthy and a weak handshake indicates the client has a weak demeanor.
Rationale 2: Communication can break down when the nurse fails to decode the messages by not actively listening to the client.
Rationale 3: It is appropriate for the nurse to create an informal atmosphere when discussing a sensitive topic with a younger client.
Rationale 4: It is appropriate for the young nurse to use a serious and respectful when discussing a sensitive topic with an older client.
Rationale 5: Communication can break down easily when nurses use words that clients do not understand. The nurse should avoid medical jargon.
Global Rationale: Communication has an increased chance of breaking down when the nurse and the client are from different cultures. Some Native Americans believe that direct eye contact is an invasion of privacy and a firm handshake can be an aggressive action. A person of Northern European descent may feel that a person who avoids direct eye contact is untrustworthy and a weak handshake indicates the client has a weak demeanor. Communication can break down when the nurse fails to decode the messages by not actively listening to the client, or by using words that clients do not understand. The nurse should avoid medical jargon. It is appropriate for the nurse to create an informal atmosphere when discussing a sensitive topic with a younger client. It is appropriate for the young nurse to use a serious and respectful when discussing a sensitive topic with an older client.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.9. Discuss principles of effective communication.
AACN Essentials Competencies: VII.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care.
NLN Competencies: Relationship Centered Care: Communicate information effectively; Listen openly and cooperatively.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 29.1: Use professional communication skills to gather subjective data in a health history.
MNL Learning Outcome:
Page Number: p. 862

Question 3
Type: FIB
The client weighs 224 pounds. How many kilograms does the client weigh?
_____ kilograms.
Standard Text: Round to the nearest tenth.
Correct Answer: 101.8 kilograms
Rationale: There are 2.2 pounds in 1 kilogram. The client weighs 224 pounds. The nurse can divide the client’s weight in pounds by 2.2 and determine that the client weighs 101.8181 kilograms. When rounded to the nearest tenth, the client weighs 101.8 kilograms.
Global Rationale: There are 2.2 pounds in 1 kilogram. The client weighs 224 pounds. The nurse can divide the client’s weight in pounds by 2.2 and determine that the client weighs 101.8181 kilograms. When rounded to the nearest tenth, the client weighs 101.8 kilograms.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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: Assessment
Learning Outcome: 29.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a patient.
MNL Learning Outcome:
Page Number: p. 862

Question 4
Type: FIB
The client weighs 145 kilograms. The client is 1.75 meters. What is this client’s body mass index (BMI) using the following formula: BMI = weight (kg)/height2 (meters)?
______.
Standard Text: Round to the nearest whole number.
Correct Answer: 47
Rationale: Body mass index (BMI) is widely used to assess appropriate weight for height using the following formula: BMI = weight (kg)/ height2 (meters). 145 divided by 1.752 = 47.3469. When rounded to the nearest whole number, the client’s BMI is 47.
Global Rationale: Body mass index (BMI) is widely used to assess appropriate weight for height using the following formula: BMI = weight (kg)/ height2 (meters). 145 divided by 1.752 = 47.3469. When rounded to the nearest whole number, the client’s BMI is 47.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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: Assessment
Learning Outcome: 29.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a patient.
MNL Learning Outcome:
Page Number: p. 862

Question 5
Type: MCSA
The nurse is interviewing the client and learns that the client has an open leg wound that has been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing the client’s wound, which piece of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions?
1. Fluid-resistant gown.
2. Shoe covers.
3. Mask.
4. Gloves.
Correct Answer: 4
Rationale 1: A fluid-resistant gown should be worn if the client’s leg drainage cannot be contained adequately and the drainage has the potential to contaminate the nurse’s clothing.
Rationale 2: Shoe covers are important to wear if the client’s drainage cannot be contained adequately and has the potential to contaminate the nurse’s shoes. Along with the shoe covers, the nurse should also wear a fluid-resistant gown and gloves if the drainage cannot be contained.
Rationale 3: A mask should be worn if the client has a productive cough.
Rationale 4: The nurse should always follow standard precautions while assessing the client. The most important personal protective equipment for the nurse to wear is a pair of gloves.
Global Rationale: The nurse should always follow standard precautions while assessing the client. The most important personal protective equipment for the nurse to wear is a pair of gloves. A fluid-resistant gown should be worn if the client’s leg drainage cannot be contained adequately and the drainage has the potential to contaminate the nurse’s clothing. Shoe covers are important to wear if the client’s drainage cannot be contained adequately and has the potential to contaminate the nurse’s shoes. Along with the shoe covers, the nurse should also wear a fluid-resistant gown and gloves if the drainage cannot be contained. A mask should be worn if the client has a productive cough.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
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: Implementation
Learning Outcome: 29.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a patient.
MNL Learning Outcome:
Page Number: p. 863