Health & Physical Assessment in Nursing, Canadian Edition by Donita D’Amico Test Bank

Health & Physical Assessment in Nursing, Canadian Edition by Donita D’Amico Test Bank

Chapter 1

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

1) A nurse is obtaining a health history from a client who reports that he is healthy and has no health concerns. As part of the health history, the nurse documents that the client reported that he has high blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. What is the most appropriate response by the nurse 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?”  

1) 2 

Explanation: 

More information is needed before the nurse could describe the client’s viewpoint as denial.

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. It is important for the nurse to understand the client’s perspective on health.

More information is needed before the nurse can determine that the client has a lack of knowledge.

There is not enough information to determine that the client is withholding information from the nurse. Also this statement could come across as the nurse accusing the client.

Assessment

Analysis

Objective 1

Page 4

Difficulty – 1

2) What is the best description of the assessment component of SOAP charting? 

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 

2) 4 

Explanation: 

Objective data obtained from the physical assessment is an example of the “O” component of SOAP charting

The client’s chief complaint is an example of subjective data, the “S” component of SOAP charting.

This is another example of subjective data, the “S” component of SOAP charting, because it is information reported by the client.

The “A” component of SOAP charting refers to conclusions drawn from the subjective and objective data obtained. 

Assessment

Knowledge

Objective 7

Page 7

Difficulty -1

A nurse is reviewing a client’s medical record. Which is an example of a constant piece of data?

The client has B negative blood type.

The blood pressure at 0900 was 110/74 mmHg.

The sodium level is 145 mmol/L.

The client is 64 years of age.

3)1

Explanation:

Constant data are things that do not typically change over time such as race, gender, or blood type.

Variable data may change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age.

Variable data may change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age.

Variable data may change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age.

Assessment

Application

Objective 4

Page – 5

Difficulty – 2

4) A nurse is developing a handout for clients in a physician’s office.  What content areas would be included 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  

4) 4 

Explanation: 

Historically the Canadian healthcare system focused on illness and symptom control but this has changed to include a broader focus with an emphasis on wellness, prevention of disease, health maintenance, and health promotion.

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.

Illness care, pain management, and prevention of complications are addressed by the health care delivery system, but are no longer the primary focus of client care. There is now an emphasis on wellness, health maintenance, and health promotion. 

The focus of healthcare in the Canada is now on wellness, prevention of disease, health promotion and health maintenance. 

Assessment

Health Promotion and Management

Knowledge

Objective 1

Page 3

Difficulty -1

5)   What is the best method for the nurse to obtain subjective data during a health assessment?

Interviewing a primary source

Reviewing an indirect source like health records

Completing a physical assessment

Obtaining information from a family member

5)1

Explanation:

During a health assessment interview, subjective data is best gathered directly from the client, the primary source.

Although subjective data can be obtained through secondary or indirect sources such as the family, caregivers, other members of the health care team, or medical records, it is best to obtain such information directly from the client. If secondary sources are used, the nurse must validate subjective data from other sources to ensure the accuracy of the information.

Objective data is obtained during the physical assessment.

A family member can report subjective data based on perceptions the client has shared with them but it is always best to obtain the subjective data directly from the client when possible.

Health

Knowledge

Objective 4

Page 5

Difficulty – 2

6) A nurse is reviewing a client’s medical records and notes various forms of information. What piece of information is an example of subjective data? 

1)Symptoms described by the client   

2)Physical examination results  

3)Results of radiographic studies  

4)Laboratory analysis reports  

6) 1 

Explanation: 

Clients can describe feelings or symptoms that cannot be observed by others. This is an example of subjective data.

Physical examination results are an example of objective data.

Results of radiographic studies are an example of objective data.

Laboratory analysis reports are an example of objective data.

Assessment

Knowledge

Objective 4

Page 5

Difficulty-1

7)  A nurse is reviewing a client’s medical records. What is an example of 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.

7) 3 

Explanation: 

“I hurt my head” is a statement made by the client and is an example of subjective data.  Subjective data are things the client experiences and communicates to the nurse. 

The nurse did not observe the child’s fall, therefore this information was communicated by the client to the nurse which is an example of subjective data.

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

Knowledge 

Objective 4

Page 5

Difficulty – 3

8) A nurse is evaluating the plan of care and notes that none of the goals have been met for the client. 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  

8) 2 

Explanation: 

Reporting the lack of achievement of the goals to the physician is not appropriate, though, reporting undesirable client physiologic responses may be. 

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. 

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

Application

Objective 5

Page 14

Difficulty – 2

9)  A nurse is obtaining a health history from the client. What phase of the nursing process is the nurse using?

      1)   Planning  

2)Assessment   

3)Diagnosis  

4)Interviewing  

 9) 2 

Explanation: 

Planning is the third phase of the nursing process and can only occur after the completion of the assessment and diagnosis. Obtaining a health history is a component of the assessment phase of the nursing process.  

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.

Formulating a diagnosis is the second phase of the nursing process and occurs after the completion of the assessment phase. Obtaining the health history is a component of the assessment phase of the nursing process.

Interviewing is the technique used by the nurse to obtain a health history from the client. Interviewing is not one of the four phases of the nursing process.

Assessment

Knowledge

Objective 5

Page 11, 12

Difficulty – 2

10) A nurse is developing a plan of care for a client.  What types of data must the nurses consider when developing nursing diagnoses?

1)Assessment, planning, and evaluation  

2)Subjective and objective  

3)Family history, laboratory results 

4)Standard and normative  

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.  

The nurse must consider all subjective and objective data collected. The nurse will make a judgment after analysis and synthesis of the collected data.

Family history and laboratory data are components of assessment data but the nurse must consider all the objective and subjective data collected not just these two elements of 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. Data collected during the assessment are compared to normative values and standards but the nurse must consider a broader range of data in the process of formulating a nursing diagnosis.

Assessment 

Knowledge

Objective 5

Page 12

Difficulty – 2

A nurse is interpreting the findings from a health assessment she completed on a college student with influenza. The student was sent home because the student dormitory was closed due to an influenza outbreak. What determinant of health is present in this situation?

Ethnocultural 

Family

Environmental

Psychological