Chapter 17 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 17 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 2

Type: MCSA

The nurse is examining a client who is diagnosed with a fracture of one floating rib. Of the following ribs, which does the nurse suspect to be fractured?

1. 1.
2. 5.
3. 9.
4. 12.

Correct Answer: 4

Rationale 1: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.

Rationale 2: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.

Rationale 3: The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7.

Rationale 4: The rib pairs of 11 and 12 are free floating and do not articulate anteriorly.

Global Rationale: The 12 pairs of ribs circle the body, form the lateral aspects of the thorax, and are attached to the vertebrae and sternum. Anteriorly, the first seven pairs of ribs articulate directly to the sternum. The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7, whereas the pairs of 11 and 12 are free floating and do not articulate anteriorly.

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: 17.1: Describe the anatomy and physiology of the respiratory system.

MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 375

 

Question 3

Type: HOTSPOT

The nurse is conducting an assessment. Where is the right anterior axillary line (ALL) located?

D

C

B

A

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

Correct Answer: 1

Rationale 1: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.

Rationale 2: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.

Rationale 3: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.

Rationale 4: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.

Global Rationale: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.

Cognitive Level: Applying

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: 17.2: Identify landmarks that guide assessment of the respiratory system.

MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 378

 

Question 4

Type: MCSA

The nurse wants to assess the apex of a client’s right lung. Which locations should the nurse place the stethoscope to assess this area on the client?

1. Intercostal space sixth rib near the sternum.
2. Intercostal space fourth rib near the axillary line.
3. Below the scapula.
4. Near the right clavicle.

Correct Answer: 4

Rationale 1: The apex of each lung is slightly superior to the inner third of the clavicle.

Rationale 2: The apex of each lung is slightly superior to the inner third of the clavicle.

Rationale 3: The apex of each lung is slightly superior to the inner third of the clavicle.

Rationale 4: The apex of each lung is slightly superior to the inner third of the clavicle.

Global Rationale: The apex of each lung is slightly superior to the inner third of the clavicle whereas the base of each lung rests on the diaphragm.

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: 17.2: Identify landmarks that guide assessment of the respiratory system.

MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 373

 

Question 5

Type: MCSA

During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. Which landmarks will the nurse use to identify this structure?

1. Clavicle.
2. Sternum.
3. First rib.
4. Vertebral column.

Correct Answer: 2

Rationale 1: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Rationale 2: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Rationale 3: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Rationale 4: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Global Rationale: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Cognitive Level: Understanding

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: 17.2: Identify landmarks that guide assessment of the respiratory system.

MNL Learning Outcome: 8.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 376