Test Bank: Health and Physical Assessment In Nursing, 3rd Edition, by DAmico,

Test Bank: Health

and Physical

Assessment In

Nursing, 3rd

Edition, by

DAmico,

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D‟Amico/Barbarito Health & Physical Assessment in Nursing, 3/e

Copyright 2016 by Pearson Education, Inc.

D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e

Chapter 1

Question 1

Type: MCSA

While conducting a health history, a client states, “I am healthy, I don‟t know why I have to be

here to get a check-up.” However, the client reports, type 2 diabetes mellitus and an unhealed

ulcer on the left foot. Based on this information, which statement by the nurse is the most

appropriate?

1. “I feel that you are in denial about your health status.”

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

3. “Do you understand what diabetes is?”

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

Correct Answer: 2

Rationale 1: More information would be needed before the nurse could attribute the client‟s

viewpoint as denial or lack of knowledge.

Rationale 2: A client will have his or her own definition of health, illness, and wellness. The

individual‟s concept of health and wellness is influenced by many factors, including age, gender,

race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and

self-expectations.

Rationale 3: The client‟s history of type 2 diabetes is a valid area requiring further investigation

but the nurse must first ascertain the client‟s definition of healthy.

Rationale 4: There is not enough information to determine the client‟s withholding of

information to the nurse.

Global Rationale: A client will have his or her own definition of health, illness, and wellness.

The individual‟s concept of health and wellness 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. The client‟s history of type 2

diabetes is a valid area requiring further investigation but the nurse must first ascertain the

client‟s definition of healthy. There is also not enough information to determine the client‟s

withholding of information to the nurse.

Cognitive Level: Analyzing

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: Personal and Professional Development: Identify problems; Contribute to

assessment of outcome achievement.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.4: Identify the key components of health assessment in nursing.

MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history

interview of a client.

Page Number: p. 3

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D‟Amico/Barbarito Health & Physical Assessment in Nursing, 3/e

Copyright 2016 by Pearson Education, Inc.

Question 2

Type: MCSA

Which information would the nurse include in the assessment category when using SOAP to

documents in the medical record?

1. The client‟s blood pressure was 177/93.

2. The recent loss of employment and insurance has prevented the client from being able to

afford prescription medications.

3. The client reports having lost her job and insurance 3 months ago.

4. Referrals have been made to social services to determine financial assistance programs

available.

Correct Answer: 2

Rationale 1: This is the “O” component; objective data.

Rationale 2: The “A” component of the SOAP note refers to conclusions drawn from the

subjective and objective data obtained.

Rationale 3: This is subjective data (“S” component).

Rationale 4: This is the “P” component, plan.

Global Rationale: The “A” component of the SOAP note refers to conclusions drawn from the

subjective and objective data obtained. The client‟s recent loss of employment and the potential

that this was a contributing factor in the inability to afford medications is an example of a

conclusion. The client‟s reported blood pressure would be an example of objective data.

Objective data is information that can be measured by the examiner. Blood pressure is not an

example of subjective information nor is it a conclusion. The client‟s reported loss of

employment and insurance is an example of subjective data. The statement does not include

conclusions as to the results of these events. Making referrals to social services is an example of

an intervention. It is not a conclusion.

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: Personal and Professional Development: Identify problems; Contribute to

assessment of outcome achievement.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.4: Identify the key components of health assessment in nursing.

MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history

interview of a client.

Page Number: pp. 5–8

Question 3

Type: MCSA

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