Chapter 12 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 12 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 has calculated the BMI (body mass index) of an adult client who weighs 169 pounds and is 6 feet in height, and has obtained a result of 23. Which interpretation of this data by the nurse is the most appropriate?

1. Mild malnutrition.
2. Normal.
3. Overweight.
4. Obese class 1.

Correct Answer: 2

Rationale 1: Mild malnutrition is considered a BMI of 17–18.49.

Rationale 2: Normal BMI ranges between 18.5 and 24.9.

Rationale 3: Overweight BMIs are between 25 and 29.9.

Rationale 4: Obese class 1 BMIs are between 30 and 34.9.

Global Rationale: Adult BMI classification places a result of 23 within the range of normal, which includes BMIs between 18.5 and 24.9. Mild malnutrition is considered a BMI of 17–18.49. Overweight BMIs are between 25 and 29.9. Obese class 1 BMIs are 30–34.9.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

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

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Define nutritional health.

MNL Learning Outcome: 1.4.1. Identify the primary nutrients and risk factors that affect nutritional status of the client.

Page Number: p. 187

Question 2

Type: MCSA

The nurse is using a dietary recall tool to obtain a nutritional history on a client. Which is the greatest limitation when using this tool to assess the client?

1. Clients do not remember liquid intake from day to day.
2. It does not reflect food preferences of the client.
3. Clients do not provide reliable nutritional information.
4. It does not reflect occasional food habits.

Correct Answer: 4

Rationale 1: The diet recall does not reflect all flood and liquids taken in during the previous 24 hours or longer.

Rationale 2: A 24-hour dietary recall does not need to reflect food preferences of the client to provide the needed information.

Rationale 3: Although a 24-hour dietary recall is not the most reliable method to obtain information, it is considered somewhat reliable.

Rationale 4: The food habits that are employed occasionally are not the focus of a 24-hour dietary recall. It is used to determine recent intake.

Global Rationale: The greatest limitation of the 24-hour dietary recall is that it does not, or may not, reflect food habits that occur occasionally but not on the day recalled. It is not the most reliable way of obtaining information since it does rely on the client’s memory; however, it is considered somewhat reliable and a useful tool for nutritional assessment. It does not need to reflect food preferences. The diet recall does reflect all food and liquids taken in during the previous 24 hours, or longer period, if asked.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: 12.6: Describe existing validated nutritional assessment tools.

MNL Learning Outcome: 1.4.2. Apply the principles of performing an assessment to determine the nutritional status of the client.

Page Number: pp. 205–208

Question 3

Type: MCSA

The nurse is obtaining tricep skinfold measurements on a client. Which locations would the nurse correctly use for this assessment?

1. Midpoint of the arm between the scapula and the elbow.
2. Two inches and centered below the scapula.
3. One inch around the umbilicus.
4. Lateral aspect of thigh.

Correct Answer: 1

Rationale 1: Tricep skinfold measurements are done at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow.

Rationale 2: Tricep skinfold measurements are done at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not 2 inches and centered below the scapula.

Rationale 3: Tricep skinfold measurements are done at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not at the umbilical region.

Rationale 4: Tricep skinfold measurements are done at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not in the lateral aspect of thigh.

Global Rationale: Tricep skinfold measurements are done at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. The remaining answers are not tricep skinfolds.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: 12.4: Identify physical and laboratory parameters utilized in a nutrition assessment.

MNL Learning Outcome: 1.4.2. Apply the principles of performing an assessment to determine the nutritional status of the client.

Page Number: pp. 196–197