Chapter 11 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 11 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 assessing pain level with vital signs for an adolescent client. The client is reporting pain but when the nurse asks for a description of the pain the client says, “It just hurts. Why can’t I have something?” Which action by the nurse is the most appropriate?

1. Leave the room and come back later.
2. Provide questions that require yes or no answers related to pain.
3. Ask the client what they would like to have for pain.
4. Continue with the vital signs assessment.

Correct Answer: 2

Rationale 1: Leaving the room will not provide effective pain management.

Rationale 2: People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as “Describe ….” The nurse may be better able to obtain an accurate description of their pain by having them respond to descriptive words.

Rationale 3: Asking the client what she would like for pain is not appropriate without a complete assessment.

Rationale 4: If the client is in pain, moving on to the vital signs will not yield additional information.

Global Rationale: People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as “Describe ….” The nurse may be better able to obtain an accurate description of their pain by having them respond to descriptive words. Leaving the room will not provide effective pain management. Asking the client what she would like for pain is not appropriate without a complete assessment. If the client is in pain, moving on to the vital signs will not yield additional information.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering.

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: 11.5: Identify cultural and developmental influences that affect assessment of pain for patients across the lifespan.

MNL Learning Outcome: 1.3.3. Apply the principles of assessing pain in the care of a client.

Page Number: p. 177

 

Question 2

Type: MCSA

The nurse is working at a pain clinic and is preparing an orientation for new staff nurses. Which of the following definitions of pain would the nurse correctly choose to include in this orientation?

1. Pain is validated by the nurse determining the cause of the pain.
2. Pain is an unpleasant sensation, typically experienced upon movement.
3. Pain is whatever the experiencing person says it is.
4. Pain is very subjective, so observations must be used to assess levels and intensity.

Correct Answer: 3

Rationale 1: At times, the cause of the pain is not determined at the time the client reports it. The nurse’s role is not to validate the client’s report but to assess and assist in alleviating or managing the pain.

Rationale 2: Pain involves unpleasant sensations, though not always limited to movement.

Rationale 3: The most widely accepted definition of pain is the one offered by McCaffery: “whatever the experiencing person says it is, existing whenever he or she says it does” (McCaffery & Pasero, 1999, p. 5).

Rationale 4: Pain is a subjective experience and the client’s report of pain must be trusted in order to effectively manage it.

Global Rationale: The most widely accepted definition of pain is the one offered by McCaffery: “whatever the experiencing person says it is, existing whenever he or she says it does” (McCaffery & Pasero, 1999, p. 5). It involves unpleasant sensations, though not always limited to movement. At times, the cause of the pain is not determined at the time the client reports it. The nurse’s role is not to validate the client’s report but to assess and assist in alleviating or managing the pain. Pain is a subjective experience and the client’s report of pain must be trusted in order to effectively manage it.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort.

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

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.1: Explore the concept of pain.

MNL Learning Outcome: 1.3.2. Classify the various sources and types of pain.

Page Number: p. 173

 

Question 3

Type: MCSA

The nurse is in the triage area of the emergency department when a client arrives complaining of chest and arm pain. The client also reports jaw pain, but states that the chest pain hurts more. The nurse observes the client rubbing his left arm. The nurse suspects which type of pain?

1. Phantom pain.
2. Radiating pain.
3. Intractable pain.
4. Cutaneous pain.

Correct Answer: 2

Rationale 1: Phantom pain is a painful sensation perceived in an absent body part or a body part that is paralyzed.

Rationale 2: The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts.

Rationale 3: Intractable pain does not respond to relief measures.

Rationale 4: Cutaneous pain is pain experienced in the cutaneous tissues.

Global Rationale: The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts. Phantom pain is a painful sensation perceived in an absent body part or a body part that is paralyzed. Intractable pain does not respond to relief measures. Cutaneous pain is pain experienced in the cutaneous tissues.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort.

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

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.1: Explore the concept of pain.

MNL Learning Outcome: 1.3.2. Classify the various sources and types of pain.

Page Number: p. 176