(Test Bank) Health & Physical Assessment In Nursing, Canadian Edition

D'Amico,Barbarito,Twomey,Harder, 1

Nursing

Test Bank

1st Edition

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Test Bank for Health & Physical Assessment In Nursing, Canadian Edition, The downloadable file consists of 346 pages, and the total size of the file is 2.85 MB. Purchase now only for highly discounted price.

Author(s): D'Amico, Barbarito, Twomey, Harder

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Test Bank for Health & Physical Assessment in Nursing, 1st Canadian Edition by Donita D'Amico, Colleen Barbarito, Creina Twomey, Nicole Harder (All Chapters) 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 n urse 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 den ial 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: 1. More information is needed before the n urse could describe the client’s viewpoint as denial. 2. 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. 3. More information is needed before the nurse can determine that the client has a lack of knowledge. 4. There is not e nough 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: 1. Objective data obtained from the physical assessment is an example of the “O” component of SOAP charting 2. The client’s chief complaint is an example of subjective data, the “S” component of SOAP charting. 3. This is another example of subjective data, the “S” component of SOAP charting, because it is information reported by the client. 4. The “A” component of SOAP charting refers to conclusions drawn from the subjective and objective data obtained. Asse ssment Knowledge Objective 7 Page 7 Difficulty -1 3) A nurse is reviewing a client’s medical record. Which is an example of a constant piece of data? 1) The client has B negative blood type. 2) The blood pressure at 0900 was 110/74 mmHg. 3) The sodium level is 145 mmol/L. 4) The client is 64 years of age. 3)1 Explanation: 1. Constant data are things that do not typically change over time such as race, gender, or blood type. 2. Variable data m ay change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age. 3. Variable data may change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age. 4. 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: 1. 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. 2. 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. 3. 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. 4. 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? 1) Interviewing a primary source 2) Reviewing an indirect source li ke health records 3) Completing a physical assessment 4) Obtaining information from a family member 5)1 Explanation: 1. During a health assessment interview, subjective data is best gathered directly from the client, the primary source. 2. Although su bjective 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, th e nurse must validate subjective data from other sources to ensure the accuracy of the information. 3. Objective data is obtained during the physical assessment. 4. 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 re viewing 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: 1. Clients can describe feelings or symptoms that cannot be observed by others. This is an example of subjective data. 2. Physical examination results are an example of objective data. 3. Results of radiog raphic studies are an example of objective data. 4. 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 stat es that she fell at the playground. 7) 3 Explanation: 1. “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. 2. The nurse did not o bserve the child’s fall, therefore this information was communicated by the client to the nurse which is an example of subjective data. 3. 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. 4. 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: 1. Reporting the lack of achievement of the goals to the physician is not appropriate, though, reporting undesirable client physiologic responses may be. 2. The plan of care should be evalua ted 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. 3. Re-formulating the nursing diagnosis to a more realistic one is not th e best course of action as the diagnosis established came from subjective and objective data specific to that diagnosis. 4. Client achievement of goals is needed regardless of status. Evaluation Application Objective 5 Page 14 Difficulty - 2 9) A nu rse 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: 1. 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. 2. Obtaining the health history is a co mponent of the assessment phase of the nursing process. The nurse cannot determine an accurate nursing diagnosis or plan of care without assessment data. 3. 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. 4. 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 evalu ation 2) Subjective and objective 3) Family history, laboratory results 4) Standard and normative 10) 2 Explanation: 1. Assessment involves the collection of subjective and objective data in order to plan and provide care for the client. Plan ning 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. 2. The nurse must consider all subjective and objective data collected. The nurse will make a judgment after analysis and synthesis of the collected data. 3. 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. 4. 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 11) 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? 1) Ethnocultural 2) Family 3) Environmental 4) Psychological 11) 3 Explanation: 1. Enthocultural factors are an example of a determinant of health; however, there is no information provided in the scenario that indicates a cultural factor is influencing the student’s health. 2. Family factors are another example of a determinant of health; however, there is no information provided in the scenario that indicates that a family factor is influencing the student’s health. 3. Environmental fac tors can affect health. Influenza is spread from person to person through coughing and sneezing, particularly in places where people live in close quar ters like student housing. There is evidence in this scenario to support an environmental determinant of health has affected this student. 4. Psychological factors are another example of a determinant of health; however, there is not information provided in this scenario to support that a psychological factor is affecting this student’s health status. Health Knowledge Objective 2 Page 4, 10, 11 Difficulty - 2 12) What statement most accurately des cribes the World Health Organization (WHO) definition of health? 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 a cu lturally defined, valued, and practiced state of well -being 4) Health is a state of complete physical, mental, and social well -being. 12) 4 Explanation: 1. The traditional view of health was the absence of illness and disease but the WHO definition is broader and includes the ideas of complete physical, mental, and social well -being. 2. This statement is a definition of health by the nursing theorist Nightingale and is not the WHO definition of health (Nightingale, 1860/1969). 3. This statement is from Leininger’s model of health and is not the WHO definition of health (Leininger, 1991). 4. This is the WHO definition of health (WHO, 1947). Assessment Comprehension Objective 1 Page 4 Difficulty - 1 13) A nurse is developing a plan of care for a cl ient with surgical incision pain. What 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. 3) The client will state understanding of the cause of pain in 3 days. 4) The client will verbalize no pain. 13) 1 Explanation: 1. “The client will verbalize pain relief" is a goal statement directly related to the nursing diagnosis, it is stated in a positive fashion, and has measurable criteria. 2. “The client will state they feel fine" is not directly related to the surgical pain and is not measurable. 3. Understanding the cause of surgical pain does not measure whether the pain has been reduce d. 4. It is unrealistic to expect a client will feel no pain following surgery. The goal statement should be realistic and measurable. Planning Knowledge Objective 5 Page – 13 Difficulty Level - 2 14) A nurse is developing the plan of care and needs t o develop interventions to achieve a specific goal. What source should the nurse use to determine interventions? 1) Nursing diagnosis 2) Defining characteristics of the nursing diagnosis 3) Etiology of the nursing diagnosis 4) Client’s stated wishe s 14) 3 Explanation: 1. The interventions are derived from the cause of the diagnosis. 2. The defining characteristics provide the background support for the diagnosis. 3. The etiology of the diagnosis is used to determine the interventions. 4. The client’s stated wishes are an important component of planning, and may be included in the list of interventions as appropriate but the primary source of interventions will be re lated to the etiology of the diagnosis. Planning Knowledge Objective - 5 Page – 13 Difficulty Level - 2 15) Ms. Benoit, 38 years old, is admitted with chest pain. What is an example of a holistic approach to nursing care? 1) Considering all the fact ors that impact Ms. Benoit’s well -being 2) Completing a thorough chest assessment 3) Reviewing Ms. Benoit’s life style 4) Obtaining a detailed family history 15) 1 Explanation: 1. Holism includes all factors that impact the client’s physical and emotional well -being, including physiological, developmental, psychological, emotional, family, cultural, and environmental factors. 2. The holistic approach should not look at just the physical problem the client is experiencing. 3. A review of lif estyle is important but does not provide a holistic approach. 4. The family history is important but does not include other aspects that may impact physical and emotional well -being. Assessment Application Objective - 4 Page 10 Difficulty - 2 16) A nurse is evaluating the client’s progress toward meeting the following objective of a teaching plan, “The client will list signs of hypoglycemia before discharge.” What missing factor will make it difficult for the nurse to evaluate whether the client has met this objective? 1) Time frame 2) Specific criteria to be met 3) Method of evaluation 4) How the information was taught 16) 2 Explanation: 1. Time frame has been included in the objective. 2. The criteria is too gen eral; the objective needs to be more specific (e.g., list 5 signs). 3. The method of evaluation is not part of the objective. 4. The teaching strategy is not part of the objective. Evaluation Knowledge Objective – 8 Page – 13, 18, 19 Difficulty - 3 17) A nurse is required to teach Mr. Hammond how to administer his insulin injection. What is an appropriate teaching strategy for the nurse to use? 1) Discussion 2) Demonstration 3) Printed directions 4) Role play 17) 2 Explanati on: 1. Discussion is best used with cognitive learning. 2. Demonstration and practice are effective strategies for teaching psychomotor skills. 3. Printed material is not effective in teaching a psychomotor skill. 4. Role play will allow an understand ing of others point of view but is not effective in teaching a psychomotor skill. Evaluation Knowledge Objective – 8 Page – 19 (Table 1.2) Difficulty - 2 18) A nurse is caring for a newly admitted patient with Methicillin -resistant Staphylococcus Aureus (MRSA). What is the primary goal of the initial health assessment? 1) Determine the client’s current state of health 2) Assess the client’s knowledge about MRSA 3) To determine client allergies 4) Determine how frequently the client is able to change positions 18) 1 Explanation: 1. 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 pr omoting activities. 2. Assessment of the client’s knowledge is important, but is not the primary goal of doing a health assessment. 3. Determining the client’s allergies is important, but the goal of a health assessment is broader. 4. It is important to determine what limitations the client has, but it is not the primary goal of a health assessment. Application Comprehension Objective - 3 Page – 5 Difficulty Level - 3 19) While the nurse assesses a client who is hospitalized for an acute exacerbatio n of chronic obstructive pulmonary disease, the client becomes 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 in formation 2) Evaluation 3) Generation of alternatives 4) Analysis of the situation 19) 4 Explanation: 1. The nurse has collected data and has analyzed the situation. 2. Evaluation looks at whether there are omissions in the critical thinking process and whether outcomes have been achieved. 3. This step looks at steps to follow to resolve a problem. 4. The nurses has analyzed the data and drawn valid conclusions. Planning Analysis Objective - 6 Page – 15 Difficulty Level - 2 20) What is an example of subjective data? 1) The bowel sounds are hyperactive in all four quadrants. 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. 20) 2 Explanation: 1. Bowel sounds are objective data. 2. Subjective data is information the client experiences and communicates to the nurse. 3. This is objective data as it can be seen /felt by the nurse. 4. This is an objective assessment made by the nurse. Assessment Application Objective –4 Page – 5 Difficulty Level - 1 21) A client with hepatitis B is admitted to the hospital. What should the nurse keep in mind regarding client confidentiality? 1) Information sharing is limited to those directly involved in the client’s care. 2) All members of th e health care team should be aware of this information. 3) This information should not be included in the client’s chart. 4) The medical records are open to any hospital employee, including administration. 21) 1 Explanation: 1. Confidentiality means that information sharing is limited to those directly involved in the client’s care. 2. Not all members of the health care team have access to the chart, only those who are directly caring for the client. 3. This information should be available to those health care professionals directly involved in the client’s care. 4. Hospital records are only open to those directly related to the care of the client. Assessment Application Objective – 4 Page – 6 Difficulty Level - 3 22) What is included in the planning step of the nursing process? 1) Setting priorities 2) Teaching the client 3) Making a referral 4) Analyzing the assessment data 22) 1 Explanation: 1. Priority setting, stating goals, and listing strategies to mee t the goals are all part of the planning process. 2. Teaching is an intervention. 3. Making a referral is an intervention. 4. Analysis of data is part of determining the nursing diagnosis. Implementation Knowledge Objective – 5 Page – 13 Difficulty Level - 2 23) Mr. James, 59 years old, is hospitalized with end stage liver failure secondary to years of alcoholism. What is the nurse’s first step when using a critical thinking approach to collect information about this client? 1) Organizing the approach to use 2) Identifying assumptions 3) Identifying missing information 4) Identifying any inconsistencies 23) 2 Explanation: 1. Before developing an organized approach to collect information the nurse needs to identify assumptions that may impact the assessm ent. 2. The nurse needs to identify assumptions that may misguide or misdirect assessment. 3. Identifying gaps in information is important, but the nurse needs to identify assumptions made about the client. 4. It is important to identify and follow -up on inconsistencies in the information, but it is not the first step. Application Comprehension Objective – 6 Page – 14 Difficulty Level - 2 24) In the nurse’s teaching plan, what objective addresses the psychomotor domain? 1) The client will discus s three interventions for low blood sugar. 2) The client will describe four symptoms of low blood sugar. 3) The client will demonstrate how to draw up the correct dose of insulin. 4) The client will define diabetes mellitus. 24) 3 Explanation: 1. This goal is in the cognitive domain. 2. This goal is in the affective domain. 3. This goal is in the psych omotor domain. 4. This goal is in the cognitive domain. Evaluation Comprehension Objective – 8 Page – 18 (Table 1.1), 19(Table 1.2) Difficulty Level - 2 25) Which statement best describes the active role of the 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) 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. 25) 1 Explanation: 1. These are the aspects of client teaching the nurse needs to consider. 2. Informal teaching does not involve teaching plans. 3. The nurse at the bedside has a role in teaching clients and cannot be delegated to others. 4. Teaching can be done in collabo ration, but the nurse at the bedside has a role as an educator. Planning Comprehension Objective – 8 Page – 17 Difficulty - 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A nurse is admitting a client and notes a place for subjective data on the history form. What method will the nurse use to gather the required subjective data? ______________________ 26) interview Explanation: Subjective data is gathered from the interviews of primary and secondary sources. The interview includes the health history and focused interview. Assessment Knowledge Objective 4 Page 5 Difficulty - 2 Chapter 2 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) What statement most accurately describes the concept of health promotion? 1) A psychological model that attempts to explain and predict health behaviours 2) A process of enabling people to increase control over their health and its determinants 3) The economic and social conditions that influence the health of individuals and their communities 4) Understanding the psychosocial and phys ical processes of disease in order to promote good health 1) 2 Explanation: 1. This statement describes the Health Belief Model. 2. This statement describes the basis of health promotion. 3. This is a description of the social determinants of health. 4. The medical model fits this description. Assessment Knowledge Objective 1 Page 23 Difficulty 2 2) A couple who both have a positive family history of sickle cell anemia are concerned about the potential of having a child with sickle cell disease. Which statement in dicates that the couple wishes to participate in primary prevention? 1) “We both need to be treated for sickle cell anemia before we can have a baby.” 2) “We will have blood tests to determine if we are carriers.” 3) “We need to see a genetics counse llor to discuss the potential for having a child with sickle cell disease.” 4) “Neither one of us has sickle cell disease, so any baby we had would be safe from the disease as well.” 2) 3 Explanation: 1. It is not stated that either partner has sickle ce ll disease, so there is no need for treatment prior to pregnancy. 2. Both individuals being tested for carrier status would be considered secondary prevention, as it deals with early detection of health problems. 3. Primary prevention focus is to improve or mai ntain health for the individual. Seeking out a genetics counselor is considered primary prevention. 4. Despite the fact that neither the man nor woman has sickle cell disease, there is still a possibility that a child could be born with the disease, dependin g on the carrier state of the parents. Diagnosis Application Objective 1 Page 30 and 31 Difficulty = 2 3) A nurse is working to develop a community garden to provide food security for people living in an impoverished area of the city. What social dete rminant of health is present in this situation? 1) Income and social status 2) Culture 3) Social environment 4) Physical environment 3) 1 Explanation: 1. Food insecurity is largely the result of low income and financial insecurity. The community garde n provides impoverished people access to affordable healthy food. 2. The community garden may be helping many marginalized people access healthy food, but it is not changing the underlying factors leading to marginalization. 3. A community garden may bring peopl e together to form a sense of community, but the main determinant of health addressed through a community garden is food security for low income people. 4. Physical environment is generally about clean air, water, and soil. Planning Application Objective 2 Page 23 Difficulty 2 4) A nurse is discharging a client who had a cerebral vascular accident (CVA ) and will be cared for at home by her husband. The nurse knows that the client’s husband understands the need for tertiary prevention when he makes which sta tement? 1) “She will need instruction on using her walker.” 2) “She will need to have her flu shot this year.” 3) “She must have coagulation studies completed weekly .” 4) “She needs to have her cholesterol checked every 2 months.” 4) 1 Explanati on: 1. Tertiary prevention focuses on reducing loss of function, maximizing health, and minimizing disability. Learning to use a walker to aid ambulation is an example of tertiary prevention to reduce the loss of function. 2. Having a yearly flu shot is an exam ple of primary prevention. 3. Having blood work taken weekly to review clotting times is a screening procedure and is an example of secondary prevention. 4. Having a cholesterol screening is an example of secondary prevention. Evaluation Application Objective 1 Page 30 and 31 Difficulty 2 5) A nurse works in a large urban hospital using telehealth to provide cardiac consultations to clients in rural settings. What principle of primary health care is evident in this scenario? 1) Public participation 2) Intersectora l cooperation 3) Activism 4) Accessibility 5)4 Explanation: 1. Public participation means that the public is fully involved in decision -making about personal health care and health system issues. This is not the focus in this scenario. 2. Intersectoral collaboratio n means that there is integration with other sectors that impact health such as education, social services, and justice. 3. Activism is the direct action (for example, political lobbying) taken to support a health goal. Activism is not one of the principles o f primary healthcare. 4. Equitable access to health and health services is one of the guiding principles of primary health care that is illustrated in the scenario where a rural population is able to access specialized healthcare through technology. Implement Application Objective 1 Page 24 and 25 Difficulty 2 6) A mother calls the provincial 'Nurse Hotline' concerned about her toddler's flu symptoms. What principle of primary healthcare is evident in this situation? 1) Public participation 2) Intersectoral collabora tion 3) Appropriate technology 4) Advocacy 6) 3 Explanation: 1. Public participation means that the public is fully involved in decision -making about personal health care and health system issues. This is not the focus in the scenario. 2. Intersectoral collaboratio n means that there is integration with other sectors that impact health such as education, social services, and justice. 3. A telephone triage system is an example of an effective and affordable technology used to benefit health and reduce the reliance on eme rgency departments. 4. Advocacy is not one of the principles of primary healthcare. Implementation Application Objective 1 Page 24 and 25 Difficulty 2 7) A nurse working in a remote northern community has notice d a sharp increase in the number of teens coming to the clinic with sexually transmitted infections (STIs). What strategy is an example of an upstream approach to the problem? 1) Have a condom machine installed in the washrooms at the high school 2) Schedule more nurses to work at the clinic to handle the increased case load 3) Hold an educational session with the students on STIs 4) Provide free condoms at the health clinic 7) 3 Explanation: