(Test Bank) Health & Physical Assessment In Nursing

D'Amico,Barbarito, 3

Nursing

Test Bank

3rd Edition

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Test Bank for Health & Physical Assessment In Nursing, The downloadable file consists of 834 pages, and the total size of the file is 6.37 MB. Purchase now only for highly discounted price.

Author(s): D'Amico, Barbarito

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Test Bank for Health & Physical Assessment In Nursing , 3e Donita D'Amico , Colleen Barbarito (All Chapters) 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 che ck-up.” However, the client reports, type 2 dia betes 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, previou s 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 t o 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 wellnes s 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 view point as denial or lack of knowledge. The clien t’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 clien t’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, implemen tation 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, us ing developmentally and culturally appropri ate approaches . NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement . Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcom e: 1.4: Identify the key components of health a ssessment in nursing. MNL Learning Outcome: 2.1.2 . Distinguish the phases of conducting the health history interview of a client. Page Number: p. 3 Question 2 Type: MCSA Which information would the nurse incl ude 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 insuran ce 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 conclu sions 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 subje ctive 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 o f 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 Ne ed: Health Promotion and Maintenance Client Nee d 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 pro blems; 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 cond ucting the health history interview of a client. Page Number: pp. 5–8 Question 3 Type: MCSA The nurse is conducting a workshop on wellness and health promotion using the initiatives of Healthy People 2020 . After the session, which statement by a participa nt indicates an understanding of the initiatives? 1. “It will allow health care providers to lobby legislators for more funding.” 2. “The primary goal of Healthy People 2020 is to assist health care providers in determining risk factors for premature birth .” 3. “Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death.” 4. “The initiatives will outline standards of care for providers in managing diseases.” Correct Answer: 3 Rationale 1: Health care providers and other pe rsons interested in programs to promote health have found the document to be a useful source of information in their efforts to gain funding. Rationale 2 : The Healthy People 2020 initiative is a 10 -year strate gy 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 o f the document co vers broad areas of concern. Rationale 3 : The Healthy People 2020 initiative is a 10 -year strategy intended to promote health, prevent illness, disability, and premature death. Rationale 4 : Standards of care in disease management is not a component of the document. Global Rationale: The Healthy People 2020 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 f actors 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 o f information in their efforts to gain funding. Standards of care in disease management are not a component of the document. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B.1. Elicit patient values, preferences , and expres sed needs as part of clinical interview, implementation of care plan , and evaluation of care . AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, co mmunities and populations . NLN Competencies: Knowledge and Practice: Health promotion/disease prevention . Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2: Relate the goals and ob jectives of Healthy People 2020 to health asses sment in nursing. MNL Learning Outcome: Page Number: pp. 2 –3 Question 4 Type: MCSA The nurse is developing a handout for clients in a healthcare provider’s office. The nurse includes which focus area in this handout to emphasize current changes in the hea lth care delivery system? 1. Class recommendations for diabetics concerning insulin administration A2.Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins . 2. Guidelines from the Cent ers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins . 3. Resources available to treat chronic pain . 4. Class listings for exercise classes available in the comm unity . Correct Answer: 4 Rationale 1: Symptom m anagement, 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. Rationale 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. Rationale 3 : Symptom management, illness care, and pain management are addressed by the health c are delivery system but are not the primary foc us, as clients are taking a more active role in managing their own care. Rationale 4 : The focus of health care in the United States today is wellness, prevention of disease, health promotion , and health mainte nance, for wh ich a listing of exercise classes is appropriate. Global Rationale: The focus of health care in the United States today is wellness, prevention of disease, health promotion, and health maintenance, for which a listing of exercise classes is appropriate. Sy mptom management, illness care, an d 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 fu nction of governmental organizations and health care providers in the community, but is not a focus of individual care. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies : III.B.3. Base individualized care plan on patient values, clinical expertis e, and evidence . AACN Essentials Competencies : IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care . NLN Competencies: Relationship Centered Care: Learn cooperatively, facilitate the learning of others. Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.7: Outline the key elements of an e ffective teaching plan. MNL Learning Outcome: Page Number: p. 20 Question 5 Type: MCSA The nurse conducts a health history while admitting a client to the acute care facility . When collecting primary subjective data, which is an appropriate source for the nurse to use? 1. The client’s physical assessm ent. 2. The client’s self -reports . 3. The client’s healthcare provider . 4. The client’s significant other . Correct Answer: 2 Rationale 1: The physical assessment will be recorded as objective data. Rationale 2 : Subjective data are gathered from the intervi ew. The interview includes the health history and focused interview. Data will come from primary and secondary sources. Rationale 3 : The client’s healthcare provider and significant other may contribute in the data collection process. The information obtai ned from friends and family members is considered subjective. This source of information is termed secondary. Rationale 4 : The client’s significant other may contribute in the data collection process but that input is classified as secondary . Global Ration ale: Subjective data are gathered from the interview. The interview includes the health history and focused interview. Data will come from primary and secondary sources. The client is considered the primary so urce of subjective information. Family members and healthcare providers are examples of secondary sources of subjective information. The physical assessment will be recorded as objective data. Cognitive Level: Applying Client Need: Health Promotion and Mai ntenance Client Need Sub: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team . AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritua l, 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 o f outcome achievement . Nursing/Integrated Conce pts: Nursing Process: Assessment Learning Outcome: 1.5: Explain the role of the professional nurse in health assessment. MNL Learning Outcome: 2.1.1 . Apply appropriate communication skills required to conduct the health history interview of a client; 2.1.3 . Apply the components of conducting the health history interview of a client. Page Number: p. 12 Question 6 Type: MCSA The nurse is reviewing a client’s medical records and notes various forms of information . Which is an example of subjective data from t his client’s medical record? 1. The client states, “My abdomen hurts on the left side after eating.” 2. The nurse notes the client’s abdomen is tender on the left side during palpation. 3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen. 4. The client’s hemoglobin is 14.1 gm/dL. Correct Answer: 1 Rationale 1: Subjective reports by the client are those feelings or symptoms that cannot be observed by others, of which “My abdomen hurts” is an example. Rationale 2 : Physical examinati on findings, laboratory analysis reports , and radiographic findings are objective data. Rationale 3 : Physical examination findings, laboratory analysis reports , and radiographic findings are objective data. Rationale 4 : Physical examination findings, labor atory analysis reports , and radiographic findings are objective data. Global Rationale: Subjective reports by the client are those feelings or symptoms that cannot be observed by others. Objective reports are those factors that are based upon observations of others. Physical examination findings, laboratory analysis reports, and radiographic findings are objective data. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSE N Competencies: I.B.1. Elicit patient values, p references , 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, p sychological, spiritual, socioeconomic, and env ironmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Personal and Professional Development: Identify problems; Cont ribute 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 Numb er: p. 12 Question 7 Type: MCSA The nurse is reviewing a client’s medical record while planning care. Which data from the medical record is an example of objective data? 1. “I hurt my head.” 2. “I am 6 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.” Correct Answer: 3 Rationale 1: Statements the client makes are subjective data. Rationale 2 : Statements the client makes are subjective data. Rationale 3 : Objective data are 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 a ge. Rationale 4 : Statements the client makes are subjective data. Global Rationale: Objective data are 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. 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 pati ents, using developmentally and culturally appr opriate approaches . NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement . Nursing/Integrated Concepts: Nursing Process: Assessment Learnin g 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. 12 Question 8 Type: MCSA The nurse is evaluating the p lan of care and notes that none of the goals ha ve been met for the client with impaired gas exchange. Which action by the nurse is the most appropriate? 1. Report the lack of achievement of the goals to the healthcare provider. 2. Review the data and modif y the plan. 3. Reformulate the nursing diagnosi s to a more realistic one. 4. Request a consult for the client to be seen by a pulmonologist. Correct Answer: 2 Rationale 1: Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client p hysiologic responses may be. Rationale 2 : 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. Rationale 3 : Reformulating 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. Rationale 4 : There are no data to support the need f or additional medical consultations. Global Rationale: The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, t hen the data need to be further assessed and the pl an modified. Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be. Reformulating the nursing diagno sis 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. There are no data to support the need for additional medical consultations. Cognitive Level: Applying Client Need: Physiological Integrity Client Ne ed Sub: QSEN Competencies: I.B.3. Provide patient -centered care with sensitivity and respect for the diversity of human experience . AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, i nterprofessional perspectives , and patient pref erences in planning, implementing, and evaluating outcomes of care. NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achieveme nt. Nursing/Integrat ed Concepts: Nursing Process: Evaluation Learni ng Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: Page Number: pp. 11 –14 Question 9 Type: MCSA The community health nurse is preparing to conduct a program for a group of nursin g students concerning health and wellness. Whic h statement by a participant indicates the most comprehensive and accurate understanding 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 ful lest 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.” Correct Answer: 4 Rationale 1: Health is much mor e than the absence of illness and disease. Rationale 2 : Defining health as a state of well -being is limiting as it does not encompass the elements of an individual’s being such as physical, mental, and social. Rationale 3 : While health does require a holis tic approach, this definition does not explore the elements with the same clarity of the correct answer. Rationale 4 : Health is defined as a state of complete physical, mental, and social well -being (WHO, 1947). Global Rationale: Health is defined a s a sta te of complete physical, mental, and social wel l- being (WHO, 1947). Health is much more than the absence of illness and disease. Defining health as a state of well -being is limiting as it does not encompass the elements of an individual’s being such as phy sical, mental, and social. While health does re quire a holistic approach, this definition does not explore the elements with the same clarity of the correct answer. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: QSEN Compet encies : III.A.1 . Demonstrate knowledge of basic scientific methods and processes . AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice . NLN Competencies: Knowledge and Practice: Health promotion/di sease prevention Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.1: Distinguish various definitions of health. MNL Learning Outcome: Page Number: pp. 3 –4 Question 10 Type: MCSA The nurse is caring for a client who is recoverin g from abdominal surgery. Which goal statement is most appropriate for the nurse to include in this client’s plan of care? 1. The client will verbalize pain relief using an intensity rating in 4 hours. 2. The client will state that he feels fine in 4 hours . 3. The nurse will observe fewer signs of pain in the client’s demeanor. 4. The nurse will reevaluate the client’s pain level every 2 hours. Correct Answer: 1 Rationale 1: The goal statement is directly related to the nursing diagnosis. Goal statements ar e stated in a positive fashion, and have measur able criteria. Rationale 2 : This statement is not related directly related to the diagnosis and is not measurable. Rationale 3 : A goal statement must be reflective of client activities. This is an incorrect an swer because it reflects activities of the nurs e and not the client. Rationale 4 : A goal statement must be reflective of the client’s activities. This is an incorrect answer because it reflects activities of the nurse and is not client directe d. Although t here is a time frame listed it is not correct a s it is related to nursing actions. Global Rationale: The goal statement is directly related to the nursing diagnosis. Goal statements are stated in a positive fashion, and have measurable criteri a. Verbalizat ion of the client of pain relief using a rating scale within a specified time period is an appropriately formatted, measurable statement. Statements by the client indicating he is feeling fine are not reflective of a measurable crite ria. Statements indicat ing actions by the nurse are not correctly form atted goals for the client. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B.3. Provide patient -centered care with sensitivity and respect for the diversity of human experience . AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives , and patient preferences in planning, implementing, and evaluating outcomes of care. NLN Competencies: Personal and P rofessional Development: Identify problems; Con tribut e to assessment of outcome achievement . Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: Page Number: pp. 11 –14 Question 11 Type: MCSA The nurse is developi ng the plan of care for a client who is recovering from abdominal surgery. Which intervention is most appropriate to address this client’s pain? 1. The healthcare provider will prescribe additional analgesics. 2. The client will have reduced pain after adm inistration of analgesics. 3. The client will vocalize reduced levels of pain within 3 hours. 4. Assist the client with guided imagery to manage pain levels. Correct Answer: 4 Rationale 1 : The prescribing of a dditional analgesics does not determine the cha racteristics of the pain and does not offer patient -driven information. Rationale 2 : This is a goal statement, not an intervention. Rationale 3 : This is a goal statement, not an intervention. Rationale 4 : Nurs ing interventions, such as assisting the client with guided imagery, are geared to assist in meeting client goals. The interventions are derived from the second part of the diagnosis, which is the etiology. The defining characteristics provide the backgrou nd support for the diagnosis. The diagnostic la bel 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 interv entions as appropriat e. The interventions are based upon nursing actions. Global Rationale: Nursing interventions are geared to assist in meeting client goals. The interventions are derived from the second part of the diagnosis, which is the etiology. The defining characterist ics provide the background support for the diag nosis. 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 b e included in the list of int erventions as appropriate. The interventions ar e based upon nursing actions. The prescribing of additional analgesics does not determine the characteristics of the pain and does not offer patient driven information. The reducti on of pain and vocalization o f pain levels within 3 hours are goal statement s, not interventions. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.C.5. Value the need for continuous improvement in clinical practice based o n new knowledge . AACN Essentials Competencies: IX.1. Conduct comprehe nsive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using d evelopmentally and cult urally appropriate approaches . NLN Competencies : Personal and Professional Development: Identify problems; Contribut e to assessment of outcome achievement . Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.6: Apply the critical thi nking process to health assessment in nursing. MNL Learning Outcome: 2.1.3 . Apply the components of conducting the health history interview of a client. Page Number: pp. 14 –17 Question 12 Type: MCSA The nurs e educato r is discussing Healthy People 2020 with a group of nursing students. One of the stude nts questions the instructor how this work will impact hospitalization. Which response by the educator is the most appropriate? 1. “Healthy People 2020 is a tool for the healthcare providers to offer informati on to their clients.” 2. “Healthy People 2020 seeks to improve health and prevent illness, disability, and premature death.” 3. “The purpose of Healthy People 2020 is to reduce health care costs for hospitalized clients.” 4. “Healthy People 2020 is seen as a tool by hospitals to reduce length of stay.” Correct Answer: 2 Rationale 1 : Healthy People 2020 is a resource tool for all health care professionals but its purpose is not to provide patient education between the healthcare provi der and client. Rational e 2: Healthy People 2020 presents a 10 -year str ategy with objectives intended to enhance health and prevent illness, disability, and premature death. Rationale 3 : Reduction of hospital costs is the not the primary purpose of Healthy People 2020 . Rationale 4: Reduction of length of stay is the not the p rimary purpose of Healthy People 2020 . Global Rationale: Healthy People 2020 presents a 10 -year strategy with objectives intended to enhance health and prevent illness, disability, and premature death. Healthy People 2020 is a resource tool for all health care professionals but its purpose is not to provide patient education between the healthcare provider and client. Reduction of hospital costs is the not the primary purpose of Healthy People 2020 . Cognitive L evel: Applying Client Need: Health Promotion an d 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 Essenti als Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities , and populations . NLN Competencies: Knowledge and Practice: Health promotion/disease prevention . Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.2: Relate the goals and objectives of Healthy People 2020 to health assessment in nursing. MNL Learning Outcome: Page Number: p. 2 Question 13 Type: MCSA The novice nurse wo rking on a medical -surgical unit is preparing a plan of care for a client admitted for irritable bowel syndrome. The goal statement is, “The client will resume normal bowel elimination patterns.” When reviewing the plan of care with the novice nurse, which statement by the preceptor is the most appropr iate? 1. “This plan of care has an appropriate goal statement which meets criteria. ” 2. “This goal statement requires a time frame to be appropriate.” 3. “This goal statemen t is not reflective of the client’s admitting diagnosis. ” 4. “This care plan is accurate and will be placed in the client’s medical record.” Correct Answer: 2 Rationale 1 : This goal statement does not meet criteria as it lacks a time frame. Rationale 2 : Time frames are an important component of goal statements and provide guidelines for when to evaluate the achievement of the goal. Rationale 3 : The defining characteristics of the diagnosis and the etiology of the diagnosis are components of the diagnostic statement. Rationale 4 : This goal sta tement does not meet criteria as it lacks a tim e frame. Global Rationale: This goal statement does not meet criteria as it lacks a time frame. Time frames are an important component of goal statements and provide guidel ines for when to evaluate the achieve ment 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 stateme nt. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B.3. Provide patient -centered care with sensitivity and respect for the diversity of human experience . AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives , and patient pr eferences in planning, implementing, and evaluating outcomes of care. NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement . Nursing/Integr ated Concepts: Nursing Process: Evaluation Lear ning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: Page Number: pp. 11 –14 Question 14 Type: MCMA The nurse is caring for a newly admitted client with Methicillin -resistant Staphylococcus Aureus (MRSA). Which are appropriate goals for the initial health assessment? Standard Text: Select all that apply. 1. Determine the client’s current state of health and ongoing health -promotion activities. 2. Predict risks to current health sta tus. 3. Use only objective data to determine cl ient allergies. 4. Determine how frequently the client is able to change positions. 5. Identify health -promoting activities. Correct Answer: 1, 5 Rationale 1: Health assessment goals are to determine the clien t’s current state of health and ongoing health -promotion activities. Rationale 2 : Health assessment activities are used to predict risks to health, and identify health status both current and future . This includes physical, social, cultural, environmental, and emotional factors including wellness behav iors, illness signs and symptoms, client strengths and weaknesses, and risk factors. Rationale 3 : The initial health assessment includes both objective and subjective information. Rationale 4 : The initial heal th assessment includes both objective and subje ctive information and seeks to determine the potential an individual has to implement health -promoting activities. Health assessment activities are used to predict risks to heal th, and identify health status. This includes physical, social, cultural, envir onmental, and emotional factors including wellness behaviors, illness signs and symptoms, client strengths and weaknesses, and risk factors. The ability of the client to change positions is not a part of the i nitial health assessment. Rationale 5 : The heal th assessment seeks to determine the potential an individual has to implement health -promoting activities. Global Rationale: Health asses sment goals are to determine the client’s current state of health and on going health -promotion activities. The initial health assessment includes both objective and subjective information and seeks to determine the potential an individual has to implement health -promoting activities. Health assessment activities are used to pr edict risks to health, and identify health stat us. This includes physical, social, cultural, environmental, and emotional factors including wellness behaviors, illness signs and symptoms, client strengths and weaknesses, and risk factors. The initial healt h assessment does not include using objective d ata to determine client allergies and is not part of the initial health assessment. Cognitive Level: Applying Client Need: Health Promot ion and Maintenance Client Need Sub: QSEN Competencies: I.B.3. Provide pa tient-centered care with sensitivity and respec t for the diversity of human experience . AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives , and patient preferences in planning, implementing, and evalu ating outcomes of care. NLN Competencies: Perso nal and Professional Development: Identify problems; Contribute to assessment of outcome achievement . Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.3: Explain the steps of the nu rsing process. MNL Learning Outcome: Page Numbe r: pp.11 –14 Question 15 Type: MCSA While conducting a physical assessment for a client with asthma, the nurse notes that the client is wheezing and documents this finding in the medical record. Which phase of critical thinking is represented by this nurse ’s actions? 1. Collection of information . 2. Evaluation . 3. Generation of alternatives . 4. Analysis of the situation . Correct Answer: 1 Rationale 1 : Collection of information is the initial step in the process . During this phase the nurse will assess avail able information and document the findings in the medical record. Rationale 2 : Evaluation is the final step in the process. During evaluat ion the nurse will determine the effectiveness of actions taken. Ration ale 3 : When generating alternatives for action the nurse will use critical thinking skills to determine available options for action. Rationale 4 : Analysis of the situation occurs when the nurse employs assessment skills to review and analyze the situation . The analysis will provide the nurse with the understanding of what the best plan of action will be. Global Rationale: Collection of information is the initial step in the process. During this phase the nurse will assess available information. Evaluation is the final step in the process. During evalua tion the nurse will determine the effectiveness of actions taken. When generating alternatives for action the nurse wi ll use critical thinking skills to determine available options for action. Analysis of the situation occurs when the nurse employs assessm ent skills to review and analyze the situation. The analysis will provide the nurse with the understanding o f what the best plan of action will be. Cognitive Level: Applying Client Need: Health Promotion and M aintenance Client Need Sub: QSEN Competencies: III.C.5. Value the need for continuous improvement in clinical practice based on new knowledge . AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spirit ual, socioeconomic, and environmental assessmen ts of health and illness parameters in patients, using developmentally and culturally appropriate approaches . NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessmen t of outcome achievement . Nursing/Integrated Co ncepts: Nursing Process: Evaluation Learning Outcome: 1.6: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 2.1.3 . Apply the components of conducting the health histor y interview of a client. Page Number: pp. 14 –17 Question 16 Type: MCMA The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Which data is considered subjective? Standard Text: Select all that apply. 1. The client’s mother info rms the nurse that her daughter has not been sleeping due to pain. 2. The client states, “I have pain in my belly t hat is 7 out of 10.” 3. Abdominal assessment reveals a firm, hard abdomen. 4. The client is we ak and looks very pale. 5. The client appears n ervous during the data collection period. Correct Answer: 1, 2 Rationale 1: Subjective data is information the client experiences and communicates to the nurse. This information can be provided by either the c lient or other individuals. Rationale 2 : Subjec tive data is information the client experiences and communicates to the nurse. Rationale 3 : Data that are observed by the examiner are termed objective data. Rationale 4 : Data that are observed by the examiner are termed objective data. Rationale 5 : Data t hat are observed by the examiner are termed objective data. Global Rationale: Subjective data is information the client experiences and communicates to the nurse. This information can be provided by either the client or other individuals. Primary subjectiv e data is information the client experiences and communicates to the nurse. Informati on provided by family is also considered subjective but is termed secondary. Assessment data that are observed by the examin er are termed objective data. Reports by the cl ient’s mother are considered secondary subjective information. The statements made by the client are referred to as primary subjective data. The characteristics of the abdomen, the client’s strength level, col or, and psychosocial assessment are termed obje ctive data. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.B.1. Elicit patient values, preferences , and expressed needs as part of clinical interview, implementation of care pla n, and evaluation of care . AACN Essentials Competencies: IX.1. Conduct comprehensive a nd focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illne ss parameters in patients, using developmentall y and culturally appropriate approaches . NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement . Nursing/Integrated Concepts: Nursing Proces s: Assessment Learning Outcome: 1.4: Identify t he 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. 12 Question 17 Type: MCSA The nur se is admitting a client to a mental health uni t for an exacerbation of bipolar disorder. When conducting the health history for this client, which is important to keep in mind regarding the client’ s confidentiality? 1. Confidentiality means that informati on sharing is limited to those directly involve d in the client care. 2. Complete client confidentiality means that all members of the health care team may have access to the chart. 3. The Health Insurance Portability and Accountability Act (HIPAA) helps to maintain client confidentiality and dictates w ho is to be communicating with the client. 4. The medical records are open to any hospital employee, including administration. Correct Answer: 1 Rationale 1 : Confidentiality means that information sharing is l imited to those directly involved in the client care. Rationale 2 : Not all members of the health care team have access to the chart, only those who are directly caring for the client. Rationale 3 : The Health Insurance Portability and Accountability Act (HI PAA) does not dictate who is allowed to communi cate with the client. Rationale 4 : The medical records are open to any hospital employee, including administration. Global Rationale: Confidentiality means that information sharing is limited to those directly involved in the client care. Not all members o f the health care team have access to the chart, only those who are directly caring for the client. The Health Insurance Portability and Accountability