Chapter 05 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 05 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

The nurse is caring for a client in the emergency department (ED) who complains of chest pain and reports that people were following her. She states, “I can’t see them but they are talking about grabbing me.” While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. Which is the priority when continuing the assessment for this client?

1. Spiritual affiliations.
2. Dietary preferences and habits.
3. Review of systems.
4. Focused psychosocial interview.

Correct Answer: 4

Rationale 1: A spiritual assessment is important, but the psychosocial interview would be a priority given the behaviors exhibited.

Rationale 2: Dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited.

Rationale 3: The physical examination is conducted after the interviewing is complete.

Rationale 4: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted.

Global Rationale: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. The physical examination is conducted after the interviewing is complete.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

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: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 90–97

Question 2

Type: MCSA

The nurse is interviewing a client prior to a physical examination. The client reports aches, pains, and abdominal discomfort. Which factor does the nurse suspect is impacting the client’s physical health?

1. Income.
2. Stress.
3. Ethnicity.
4. Occupation.

Correct Answer: 2

Rationale 1: Income may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Rationale 2: Stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”

Rationale 3: Ethnicity may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Rationale 4: Occupation may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Global Rationale: All of the above factors may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”

Cognitive Level: Remembering

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: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 89–90

Question 3

Type: MCSA

The nurse is interviewing an overweight adolescent who looks downward and speaks softly when answering questions. The nurse identifies a problem with client’s self-concept. Which finding supports the nurse’s conclusion?

1. Increased desire to form lasting relationships.
2. Decreased ability to form attachments with other people.
3. Inability to maintain stable employment.
4. Feelings of worthlessness, anxiety, and/or depression.

Correct Answer: 4

Rationale 1: The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.

Rationale 2: Decreased ability to form attachments to other people results from many factors not limited to poor self-concept.

Rationale 3: Decreased ability to maintain stable employment results from many factors not limited to poor self-concept.

Rationale 4: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues.

Global Rationale: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Decreased ability to maintain stable employment and to form attachments to other people results from many factors not limited to poor self-concept. The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.

Cognitive Level: Remembering

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 92–93