Health & Physical Assessment in Nursing 1st edition D’Amico, Barbarito Test Bank

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  • Published: 2007
  • ISBN-13: 978-0130493736
  • ISBN-10: 0130493732

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health and physical assessment in nursing 1st edition test bank

Chapter 1

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

1)   The nurse is obtaining a health history from a client who reports that they are healthy and has no health concerns. As part of the health history, the nurse documents that the client reported that they have high blood pressure and suffer from a leg ulcer that remains unhealed after 6 months. Which of the following statements would be the best choice for the nurse to use at this point in the interview?

1)   “I feel that you may be in denial about your health status.”

2)   “Tell me about your definition of being healthy.”

3)   “Do you understand what hypertension is?”

4)   “Is there anything else you are not telling me?”

 

 

2)   The nurse is documenting in the client’s medical record and wishes to use SOAP charting. The nurse understands that assessment refers to which of the following?

1)   objective data obtained from the physical assessment

2)   the client’s chief complaint

3)   subjective statements the client makes regarding feelings

4)   conclusions drawn from the data obtained

 

3)   The nurse is presenting a workshop on wellness and health promotion and uses Healthy People 2010 as a resource for this topic. Which of the following would the nurse include in this workshop to describe the Healthy People 2010 initiative? The document:

1)   allows health care providers to lobby legislators for more funding.

2)   assists health care providers in determining risk factors for premature birth.

3)   promotes health, prevent illness, disability, and premature death.

4)   outlines standards of care for providers in managing diseases.

 

 

4)   The nurse is developing a handout for clients in a physician’s office. The nurse would include which of the following focus areas in this handout to emphasize current changes in the healthcare delivery system?

1)   symptom management, environmental control

2)   management of outbreaks of disease, eradicating the use of toxins

3)   illness care, pain management, prevention of complications

4)   wellness, health maintenance, health promotion, prevention of disease

 

 

SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.

 

5)   The nurse is admitting a client and notes a place for subjective data on the history form. The nurse understands that subjective data is gathered from the ______________________.

 

 

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

 

6)   The nurse is reviewing a client’s medical records and notes various forms of information. The nurse understands that which of the following is subjective data?

1)   symptoms described by the client

2)   physical examination results

3)   results of radiographic studies

4)   laboratory analysis reports

 

 

7)   The nurse is reviewing a client’s medical records and notes various information. The nurse understands that which of the following is objective data?

1)   “I hurt my head.”

2)   “I am six-years-old and I’m here because I fell.”

3)   “Six-year-old Hispanic female sitting on examination table holding a towel to her forehead.”

4)   “Client states that she fell at the playground.”

 

 

8)   The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. What should the nurse do next in this situation?

1)   report the lack of achievement of the goals to the physician

2)   review the data and modify the plan

3)   re-formulate the nursing diagnosis to a more realistic one

4)   nothing as long as the client is stable

 

 

9)   The nurse is obtaining a health history from the client. The nurse recognizes that this is which part of the nursing process?

1)   planning

2)   assessment

3)   diagnosis

4)   interviewing

 

10) The nurse is developing a plan of care for a client. Which of the following are types of data the nurse must consider when identifying nursing diagnoses?

1)   assessment, planning, and evaluation

2)   subjective and objective

3)   family history, laboratory results, and the history and physical

4)   standard and normative

 

 

 

11) The nurse writes the following nursing diagnosis for an adult client with shortness of breath, dyspnea on exertion, wheezing, coughing, “feeling dizzy” and who has a respiratory rate of 32 breaths per minute: Impaired Gas Exchange secondary to inadequate oxygenation as evidenced by shortness of breath, dyspnea on exertion, wheezing, coughing, tachypnea and dizziness. Which phase of the nursing process has the nurse utilized by this step?

1)   assessment

2)   planning

3)   implementation

4)   diagnosis

 

 

12) Which of the following statements regarding health is the most comprehensive and accurate?

1)   Health is the absence of illness, disease, and symptoms.

2)   Health is a state of well being and the use of every power the person possesses to the fullest extent.

3)   Health is the state when a person is viewed as a holistic being.

4)   Health is a state of complete physical, mental, and social well-being.

 

 

13) The nurse is developing a plan of care for a client with surgical incision pain. Which of the following is the most appropriate goal statement for this client?

1)   The client will verbalize pain relief using an intensity rating in 4 hours.

2)   The client will state that they feel fine in 4 hours.

3)   The client will state understanding of the cause of pain in 3 days.

4)   The client will verbalize no pain.

 

 

14) The nurse is developing the plan of care and needs to determine interventions to achieve a specific goal. The nurse understands that interventions must be derived from the:

1)   diagnostic label itself.

2)   defining characteristics of the nursing diagnosis.

3)   etiology of the nursing diagnosis.

4)   client’s stated wishes.

 

 

15) The nurse is beginning an interview with a client and wishes to utilize a holistic approach in the delivery of care. The nurse must recognize which of the following when utilizing such an approach with clients?

1)   developmental, psychological, emotional, family, cultural, environmental and physiologic factors affect the client’s well being

2)   emotional, family and cultural factors impact the client’s well being

3)   developmental and family factors have the most impact on the client’s well being and must be the priority of care

4)   developmental and emotional factors also impact the client’s well being

 

 

16) The nurse is evaluating the client’s progress toward meeting the following goal, “The client will resume normal bowel elimination patterns.” The nurse is unable to evaluate this goal adequately due to what is missing factor?

1)   time frame

2)   defining characteristics of the diagnosis

3)   etiology

4)   statement regarding the nurse’s role in achieving the goal

 

17) A client who is hospitalized has just completed reading a brochure entitled Healthy People 2010. She asks the nurse to explain what Healthy People 2010 is about and how it impacts her hospitalization. The best response by the nurse would be:

1)   “We need to distribute these brochures to each hospitalized client. Your physician will explain how it impacts your hospitalization.”

2)   “Healthy People 2010 strives to improve health and prevent illness, disability and premature death. In the hospital we follow any guidelines that apply to your care. ”

3)   “It was left here by the previous patient. It should not impact your care at all.”

4)   “The purpose of Healthy People 2010 is to shorten your stay in the hospital. It will decrease your hospital bill.”

 

 

18) The nurse is caring for a newly admitted patient with Methicillin-resistant Staphylococcus Aureus (MRSA). Which of the following are appropriate goals of the initial health assessment? (Select all that apply.)

1)   Determine the client’s current state of health and ongoing health-promotion activities.

2)   Predict risks to current health status.

3)   Use only objective data to determine client allergies.

4)   Determine how frequently the client is able to change positions.

5)   Identify health promoting activities.

6)   Assess environmental factors which may have impacted the client’s state of health.

 

 

19) While the nurse assesses a client who is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD), the client becomes very short of breath. The nurse recognizes the need to stop the assessment to initiate respiratory support interventions. This is an example of which phase of critical thinking:

1)   Collection of information

2)   Evaluation

3)   Generation of alternatives

4)   Analysis of the situation

 

 

20) Distinguish which of the following are examples of subjective data utilized by the nurse. (Select all that apply.)

1)   The client’s mother informs the nurse that her daughter has not been sleeping due to pain.

2)   The client states, “I have pain in my belly that is 7 out of 10.”

3)   Abdominal assessment reveals a firm, hard abdomen.

4)   The client is weak and looks very pale.

 

 

21) A client with hepatitis B is admitted to the hospital. When obtaining the physical assessment, what should the nurse keep in mind regarding client confidentiality

1)   Confidentiality means that information sharing is limited to those directly involved in the client care.

2)   Complete patient confidentiality means that all members of the health care team may have access to the chart.

3)   Health Insurance Portability and Accountability Act (HIPAA) helps to maintain client confidentiality and dictates who is to be communicating with the client.

4)   The medical records are open to any hospital employee, including administration.

 

22) Identify the correct sequencing of the steps of the nursing process.

1)   Diagnosis, Assessment, Planning, Implementation, Evaluation.

2)   Assessment, Diagnosis, Planning, Implementation, Evaluation.

3)   Planning, Assessment, Diagnosis, Implementation, Evaluation.

4)   Assessment, Planning, Diagnosis, Implementation, Evaluation.

 

 

23) A client is hospitalized with end stage liver failure secondary to many years of alcoholism. The nurse begins collection of information by first:

1)   Organizing how to proceed with the client and generating alternatives to the approach.

2)   Identifying assumptions that can misguide or misdirect the assessment and intervention process.

3)   Collecting information and determining its relevance as far as impacting the client care.

4)   Identifying any inconsistencies in the communication from the client and or significant others.

 

 

24) In the nurse’s teaching plan, which of the following reflects an objective addressing the psychomotor domain?

1)   The client will discuss measures to take when feeling as if they are experiencing low blood sugar.

2)   The client will describe signs and symptoms of low blood sugar.

3)   The client will demonstrate how to draw up the correct dose of insulin.

4)   The client will define the dimensions of diabetes mellitus.

 

25) Which of the following statements best describes the active role of the professional nurse as an educator?

1)   Nurses must consider learning needs, goals, objectives, content, teaching methods and evaluation when carrying out client education.

2)   Teaching plans are developed for informal teaching when distinct needs are identified or when common needs are recognized.

3)   As the role of educator, the nurse should refer the client to other health care providers who specialize in the area of need.

4)   Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator.

 

 

 

 

Chapter 1: Answer Key

 

1) 2

Explanation:

A client will have his or her own definition of health, illness, and wellness, that is influenced by many factors including age, gender, race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and self expectations. More information would be needed before the nurse could attribute the client’s viewpoint as denial or lack of knowledge. There is also not enough information to determine the client’s withholding of information to the nurse.

Assessment

Health Promotion and Maintenance

Analysis

 

2) 4

Explanation:

The “A” component of the SOAP note refers to conclusions drawn from the subjective and objective data obtained. It is not a summary of objective data obtained from the physical assessment nor is it the reason the client sought health care. That would be subjective data. Subjective statements the client makes about how feelings are also subjective data.

Assessment

Health Promotion and Maintenance

Knowledge

 

3) 3

Explanation:

The Healthy People 2010 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death. The document identifies leading health indicators that reflect public health concerns. Risk factors for premature birth may be part of those health indicators, but the scope of the document covers broad areas of concern. Health care providers and other persons interested in programs to promote health have found the document to be a useful source of information in their efforts to gain funding. Standards of care in managing disease is not a component of the document.

Assessment

Health Promotion and Maintenance

Knowledge

 

4) 4

Explanation:

The focus of health care in the United States today is wellness, prevention of disease, health promotion and health maintenance. Symptom management, illness care and pain management are addressed by the health care delivery system, but are not the primary focus as clients are taking a more active role in managing their own care. Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care.

Assessment

Health Promotion and Management

Knowledge

 

5) interview

Explanation:

Subjective data is gathered from the interview. The interview includes the health history and focused interview. Data will come from primary and secondary sources.

Assessment

Health Promotion and Maintenance

Knowledge

 

6) 1

Explanation:

Clients can describe feelings or symptoms that cannot be observed by others. Others can report what the client has said to them but may not observe the feelings or symptoms the client reports. Physical examination findings, laboratory analysis reports and radiographic findings are objective data.

Assessment

Health Promotion and Maintenance

Knowledge

 

7) 3

Explanation:

Objective data is data that can be observed or measured by the nurse. The nurse can see the child holding the towel to her head and can use her birth date to determine her age. Statements the client makes are subjective data.

Assessment

Health Promotion and Maintenance

Knowledge

 

8) 2

Explanation:

The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified. Report the lack of achievement of the goals to the physician is not appropriate, though, reporting undesirable client physiologic responses may be. Re-formulating the nursing diagnosis to a more realistic one is not the best course of action as the diagnosis established came from subjective and objective data specific to that diagnosis. Client achievement of goals is needed regardless of status.

Evaluation

Physiological Integrity

Application

 

9) 2

Explanation:

Obtaining the health history is a component of the assessment phase of the nursing process. The nurse cannot determine an accurate nursing diagnosis or plan of care without assessment data.

Assessment

Health Promotion and Maintenance

Knowledge

 

10) 2

Explanation:

Assessment involves the collection of subjective and objective data in order to plan and provide care for the client. Planning is the process that occurs after the assessment data has been collected and interpreted. Evaluation is the process of examining the goal to see achievement. Family history, laboratory data, and the history and physical are components of assessment data. Standard and normative data are found on charts (for example, growth charts) or in results of studies to achieve the goal of establishing norms for groups of people. While those types of data may be helpful in the nursing process, they are not the types of data collected for assessment purposes.

Assessment

Health Promotion and Maintenance

Knowledge

 

11) 4

Explanation:

Diagnosis is the phase of the process whereby the nurse makes a judgment after analyzing and synthesizing all of the data collected. The assessment phase is the phase of data collection. Planning is the process of determining goals and outcome criteria and interventions, and Implementation is performing those interventions.

Diagnosis

Health Promotion and Maintenance

Knowledge

 

12) 4

Explanation:

Health is defined as a state of complete physical, mental, and social well-being (WHO, 1947). Health is much more than the absence of illness and disease.

Assessment

Physiological Integrity

Comprehension

 

13) 1

Explanation:

“The client will verbalize pain relief….” is a goal statement directory related to the nursing diagnosis, is stated in a positive fashion, and has measurable criteria. “The client will state they feel fine….” is not related directly related to the diagnosis and is not measurable. “The client will understand the cause of pain….” and “The client will verbalize not pain……” are incorrect because the former is not specific to the diagnosis and the latter does not measure pain relief or contain a time frame.

Planning

Health Promotion and Maintenance

Knowledge

 

14) 3

Explanation:

The interventions are derived from the second part of the diagnosis, which is the etiology. The defining characteristics provide the background support for the diagnosis. The diagnostic label is global and requires specification before attempting to determine a goal. The client’s stated wishes are an important component of planning, and may be included in the list of interventions as appropriate.

Planning

Health Promotion and Maintenance

Knowledge

 

15) 1

Explanation:

Holism includes all factors that impact the client’s physical and emotional well being, including physiological, developmental, psychological, emotional, family, cultural, and environmental factors. Some factors may carry a greater weight than others at various times, but all will affect immediate and long-term actual and potential health goals, problems, and plans.

Assessment

Health Promotion and Maintenance

Knowledge

 

16) 1

Explanation:

Time frames are an important component of goal statements and provide guidelines for when to evaluate the achievement of the goal. The defining characteristics of the diagnosis and the etiology of the diagnosis are components of the diagnostic statement. The nurse’s role in achieving the goal is not a component of the goal statement.

Evaluation

Health Promotion and Maintenance

Knowledge

 

17) 2

Explanation:

Healthy People 2010 presents a ten year strategy with 467 objectives intended to enhance health and prevent illness, disability, and premature death. Shortening the client’s stay is not the overall goal of Healthy People 2010. Delegating or placing responsibility on the physician is not appropriate in this case. It is also inappropriate to tell the client that the information in the brochure does not impact them.

Implementation

Health Promotion and Maintenance

Comprehension

 

18) 1, 2, 5, 6

Explanation:

Health assessment goals are to determine the client’s current state of health and ongoing health-promotion activities, predict risks to health, and identify health promoting activities. This includes physical, social, cultural, environmental, and emotional factors including wellness behaviors, illness signs and symptoms, client strengths and weaknesses, and risk factors. Using objective data to determine client allergies is not part of the initial health assessment.

Application

Health Promotion and Maintenance

Comprehension

 

19) 4

Explanation:

The first step in critical thinking is the collection of information, but this also involves analysis of the situation. The other steps are generation of alternatives, selection of alternatives, and evaluation.

Planning

Health Promotion and Maintenance

Evaluation

 

20) 1, 2

Explanation:

Subjective data is information the client experiences and communicates to the nurse.

Assessment

Physiological Integrity

Application

 

21) 1

Explanation:

Confidentiality means that information sharing is limited to those directly involved in the client care.

Not all members of the health care team have access to the chart, only those who are directly caring for the client. Hospital records are only open to those directly related to the care of the client.

Assessment

Physiological Integrity

Application

 

22) 2

Explanation:

The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client.

Implementation

Safe, Effective Care Environment

Knowledge

 

23) 2

Explanation:

The first element in critical thinking is the collection of information. Collection of information begins with 1) identifying assumptions, 2) organizing the approach, 3) determining the reliability and accuracy of the information, 4) distinguishing between relevant and irrelevant information, and 5) looking for any inconsistencies in the information.

Application

Health Promotion and Maintenance

Comprehension

 

24) 3

Explanation:

In the teaching plan the objectives identify specific, measurable behaviors or activities expected of the client. Action verbs may be from the cognitive, affective, or psychomotor domain.

Evaluation

Health Promotion and Maintenance

Comprehension

 

25) 1

Explanation:

Roles of the professional nurse include: teacher, both formal and informal, caregiver, and client advocate. The professional nurse may also have advanced practice roles. Informal teaching does not involve teaching plans. Oftentimes, teaching is done in collaboration with the advanced practice nurse specialist or the nurse educator. However, if the nurse at the bedside delegates all of the teaching to the advanced practice nurse, the delegating nurse is not fulfilling the role of the nurse as an educator.

Planning

Health Promotion and Maintenance

Comprehension

health and physical assessment in nursing 1st edition test bank