Chapter 08 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 08 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: MCMA

The student nurse is preparing to perform a health history interview. Which statements indicate that the student nurse requires further education regarding the purpose of the health history?

Standard Text: Select all that apply.

1. “As the nurse, I will mainly focus on the course of the client’s illness.”
2. “The client’s health history can be gathered during the initial interview.”
3. “I realize that the client is sick, but I also need to perform a wellness assessment.”
4. “The healthcare provider’s and nurse’s assessments should be almost identical with the same focus.”
5. “The nurse typically has a more holistic point of view regarding the client’s health.”

Correct Answer: 1, 4

Rationale 1: The healthcare provider will typically focus on the client’s illness, while the nurse will focus on the client.

Rationale 2: The nurse can gather the health history during the initial interview.

Rationale 3: The nurse should perform a wellness assessment as part of the health history.

Rationale 4: The healthcare provider’s focus and the nurse’s focus regarding the client’s health differ significantly. The nurse’s health history may produce information about a medical diagnosis, but the focus is on the client’s response to the health concern as a whole person. The healthcare provider focuses on specific body systems or body parts of the client.

Rationale 5: The nurse does typically have a more holistic view of the client when compared to the healthcare provider’s point of view.

Global Rationale: The healthcare provider will typically focus on the client’s illness, while the nurse will focus on the client. The healthcare provider’s focus and the nurse’s focus regarding the client’s health differ significantly. The nurse’s health history may produce information about a medical diagnosis, but the focus is on the client’s response to the health concern as a whole person. The healthcare provider focuses on specific body systems or body parts of the client. The nurse can gather the health history during the initial interview. The nurse should perform a wellness assessment as part of the health history. The nurse does typically have a more holistic view of the client when compared to the healthcare provider’s point of view.

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 patients, using developmentally and culturally appropriate approaches,

NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.1: Discuss the purpose of the nursing health history.

MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history interview of a client.

Page Number: p. 127

Question 2

Type: MCMA

The client has been diagnosed with an early stage of wide-angle glaucoma. The nurse is performing a wellness assessment during the client’s initial interview. Which statements by the client may be elicited during this portion of the health history?

Standard Text: Select all that apply.

1. “My mom was diagnosed with glaucoma when she was 60 years old.”
2. “I pay attention to the foods that I eat, because I want my body to stay well.”
3. “I think I do a good job of managing stress with yoga every day and running three times a week.”
4. “My husband and I have three couples that we would classify as our very good friends.”
5. “Sometimes, my eyes feel very tired and sort of ache.”

Correct Answer: 2, 3, 4

Rationale 1: The nurse should ask about the client’s family history at some point during the health history but not during the wellness assessment.

Rationale 2: The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is nourishing the body during the wellness assessment.

Rationale 3: The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is managing stress during the wellness assessment.

Rationale 4: The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is interacting socially during the wellness assessment.

Rationale 5: The nurse should ask about the client’s symptoms related to the condition but not during the wellness assessment.

Global Rationale: The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how the client is nourishing the body, managing stress, and interacting socially. The client was diagnosed with glaucoma; information about the client’s eyes may be gathered as the nurse focuses on the client’s health concerns or illness. The nurse should ask about the client’s family history at some point during the health history but not during the wellness assessment. The nurse should ask about the client’s symptoms related to the condition but not during the wellness assessment.

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 patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.1: Discuss the purpose of the nursing health history.

MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history interview of a client.

Page Number: p. 127

Question 3

Type: MCMA

The nurse is performing a focused interview with the client. Which behaviors indicate that the client may be feeling anxious?

Standard Text: Select all that apply.

1. While seated, the client begins to wiggle his foot back and forth quickly.
2. The client leans back in his chair and seems to move away from the nurse.
3. The client crosses his arms and becomes very quiet.
4. The client leans forward in the chair and uncrosses his legs.
5. The client seems to be distracted and is no longer making direct eye contact with the nurse.

Correct Answer: 1, 2, 3, 5

Rationale 1: If the client seems restless, this can indicate that the client is anxious.

Rationale 2: The client who leans back in his chair may be anxious and feels invaded by the nurse’s questions.

Rationale 3: The client who crosses his arms is expressing anxiety.

Rationale 4: The client who leans forward in his chair and uncrosses his arms is not displaying anxiety. This behavior indicates that the client is preparing to “open up.”

Rationale 5: The client who seems distracted may be disengaging from the nurse’s interview due to anxiety.

Global Rationale: If the client seems restless, this can indicate that the client is anxious. The client who leans back in his chair may be anxious and feels invaded by the nurse’s questions. The client who crosses his arms is expressing anxiety. The client who seems distracted may be disengaging from the nurse’s interview due to anxiety. The client who leans forward in his chair and uncrosses his arms is not displaying anxiety. This behavior indicates that the client may be preparing to “open up” with the nurse.

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 patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.2: Summarize components of the nursing health history for patients across the life span.

MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history interview of a client.

Page Number: p. 142