Chapter 18 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 18 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 is conducting a breast health workshop for a group of women. Which would the nurse include in this workshop when outlining risk factors for breast cancer?

Standard Text: Select all that apply.

1. Caucasian race.
2. Positive family history.
3. Low socioeconomic status.
4. Hormone replacement therapy.
5. Female age 35 to 40.

Correct Answer: 1, 2, 3, 4

Rationale 1: Caucasian females, especially over the age of 40, have a higher risk of developing breast cancer than any other race or ethnic group.

Rationale 2: A positive family history of breast cancer places an individual at a higher risk of developing breast cancer. The individual is at an even greater risk if the family member developed breast cancer prior to menopause.

Rationale 3: Lower socioeconomic status places an individual at risk for breast cancer for a number of reasons, including lack of education on preventative measures and diagnostic recommendations; fear that breast cancer is not treatable and has a high mortality rate, thus they avoid diagnosis; and the mother of the family in lower socioeconomic groups often places her family’s health care needs above hers.

Rationale 4: Hormone replacement therapy is linked to higher incidence of breast cancer.

Rationale 5: Females over the age of 40, not between the ages of 35 to 40, have been found to have a high incidence of breast cancer.

Global Rationale: Caucasian females over the age of 40, positive family history, low socioeconomic status, and taking hormone replacement therapy are risk factors for breast cancer. Females from 35 to 40 years of age are not at a high risk for developing breast cancer.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations.

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

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18.7: Relate Healthy People 2020 objectives to issues of the female breasts and axillae.

MNL Learning Outcome:

Page Number: pp. 433–436

Question 2

Type: MCSA

The nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infant’s nipple. Which conclusion by the nurse based on this data is the most appropriate?

1. The newborn has a congenital anomaly.
2. This is a highly irregular finding.
3. This is a reason to call in a specialist.
4. This is a common finding in a newborn.

Correct Answer: 4

Rationale 1: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones. This is not considered a congenital anomaly.

Rationale 2: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones; therefore, this is not considered an irregular finding.

Rationale 3: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones; therefore, there would be no reason to contact a specialist.

Rationale 4: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones; therefore, this assessment finding is common in newborns.

Global Rationale: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy. Some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones. This is neither irregular nor hereditary, and there is no reason to call on a specialist.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: 18.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

MNL Learning Outcome: 9.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 444

Question 3

Type: MCSA

A female client is hospitalized with injury and tissue destruction of the left pectoralis major and serratus anterior muscles due to a motor vehicle accident. The nurse would include which information during the discharge teaching?

1. Prosthetic devices.
2. Support bras.
3. Plastic surgery.
4. Physical therapy.

Correct Answer: 2

Rationale 1: A prosthetic device is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary.

Rationale 2: Discharge teaching regarding the need for the client to wear a support bra would be indicated in this scenario since injury has occurred to the left pectoralis major and serratus anterior muscles, as these comprise the suspensory ligaments of the breasts.

Rationale 3: Plastic surgery is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary.

Rationale 4: Physical therapy is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary.

Global Rationale: The overall contour of the breasts is determined by the suspensory ligaments, which provide support, and the major muscles of support are the pectoralis major and serratus anterior muscles. The major function of the muscles of the chest wall is to support breast and lymphatic tissue. Undergarments, which provide needed support after discharge, are an important part of the client’s recovery—for emotional as well as physical health. Although prostheses, plastic surgery, and physical therapy may all be part of the comprehensive care plan, supporting the breast and lymph tissue until such time as muscle strength is restored or reconstructed would be an important nursing intervention.

Cognitive Level: Analyzing

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: Implementation

Learning Outcome: 18.1: Describe the anatomy and physiology of the breasts and axillae.

MNL Learning Outcome: 9.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 424