Chapter 30 Kozier And Erbs Fundamentals of Nursing 10th Edition by Berman Snyder

Chapter 30 Kozier And Erbs Fundamentals of Nursing 10th Edition by Berman Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment?

1. Auscultate, percuss, palpate, inspect
2. Inspect, auscultate, palpate, percuss
3. Inspect, auscultate, percuss, palpate
4. Palpate, percuss, auscultate, inspect

Correct Answer: 3

Rationale 1: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Rationale 2: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Rationale 3: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Rationale 4: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen.

MNL Learning Outcome: 3.2.4. Apply the proper techniques and considerations to perform auscultation.

Page Number: 514

 

Question 2

Type: MCSA

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being

1. cyanosis.
2. jaundice.
3. pallor.
4. erythema.

Correct Answer: 2

Rationale 1: Cyanosis is a bluish color to the skin, mucous membranes, or nails.

Rationale 2: Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye.

Rationale 3: Pallor is a term used to describe paleness.

Rationale 4: Erythema is a term used to describe redness.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Demonstrate appropriate documentation and reporting of health assessment..

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 524

 

Question 3

Type: MCSA

While performing an assessment of the integument system, the nurse notes the client’s eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding?

1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic

Correct Answer: 3

Rationale 1: Erythema is a term used to describe redness.

Rationale 2: Cyanosis is a term used to describe a bluish cast to the skin, nails, or mucous membranes.

Rationale 3: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression.

Rationale 4: Normocephalic is a term used to describe a normal sized head.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: e. Assessing the skull and face.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 533

 

Question 4

Type: MCSA

The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel?

1. Vital signs
2. Filling of water pitchers
3. Skull and face assessment
4. Ambulation of surgical clients

Correct Answer: 3

Rationale 1: Vital signs can appropriately be delegated to unlicensed assistive personnel.

Rationale 2: Filling of water pitchers can be appropriately delegated to unlicensed assistive personnel.

Rationale 3: Assessment of the skull and face may not be delegated to unlicensed assistive personnel.

Rationale 4: Ambulation of surgical clients can be appropriately delegated to unlicensed assistive personnel.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Recognize when it is appropriate to delegate assessment skills to unlicensed assistive personnel.

MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.

Page Number: 533