Chapter 14 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 14 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 nurse assesses the client’s temporomandibular joint after the client’s states chronic pain in this location. Which manifestations would the nurse anticipate as a result of this chronic pain?

Standard Text: Select all that apply.

1. The client has developed migraine headaches.
2. The client is unable to chew well and has lost weight since the pain began.
3. The client exhibits difficulty speaking clearly and enunciating words.
4. The client has developed hyperparathyroidism.
5. The client has developed torticollis.

Correct Answer: 2, 3, 5

Rationale 1: Clients with temporomandibular joint pain are more likely to develop cluster or tension headaches.

Rationale 2: Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss.

Rationale 3: Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss.

Rationale 4: Pain at the site of temporomandibular joint is not associated with hyperparathyroidism.

Rationale 5: The client with temporomandibular joint pain can also develop painful muscle spasms in the neck called torticollis.

Global Rationale: Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. The client with temporomandibular joint pain can also develop painful muscle spasms in the neck called torticollis. Clients with temporomandibular joint pain are more likely to develop cluster or tension headaches than migraine headaches. Pain at the site of temporomandibular joint is not associated with hyperparathyroidism.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: 14.1: Identify the anatomy and physiology of the structures of the head and neck.

MNL Learning Outcome: 3.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 261

Question 2

Type: HOTSPOT/MCSA

The nurse is assessing the client’s neck. Where is the axis located?

1. A.
2. B.
3. C.
4. D.

Correct Answer: 1

Rationale 1: The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head.

Rationale 2: The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head.

Rationale 3: The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head.

Rationale 4: The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head.

Global Rationale: The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: 14.1: Identify the anatomy and physiology of the structures of the head and neck.

MNL Learning Outcome: 3.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 261

Question 3

Type: MCSA

The nurse is performing an assessment of the client’s head and neck. The client requests information about the assessment of her lymph nodes. Which response by the nurse is the most appropriate?

1. “Sometimes, enlarged lymph nodes indicate an infection.”
2. “All of your lymph nodes should be easily palpable.”
3. “The lymph system makes antibiotics to treat infection.”
4. “When one lymph node is identified as being enlarged, this is always an abnormal finding.”

Correct Answer: 1

Rationale 1: The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection.

Rationale 2: Lymph nodes should not be palpable.

Rationale 3: The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection.

Rationale 4: It is not necessarily abnormal to be able to palpate one enlarged lymph node.

Global Rationale: The head and neck are supplied by a large number of lymph nodes. The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection. Lymph nodes should not be palpable. The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection. It is not necessarily abnormal to be able to palpate one enlarged lymph node.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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: 14.1: Identify the anatomy and physiology of the structures of the head and neck.

MNL Learning Outcome: 3.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: pp. 264–265