Chapter 19 Health Assessment

Chapter 19 Health Assessment

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A nurse is doing an assessment on a 6-hour postpartum client. The client had an uncomplicatedlabor and a vaginal delivery with an epidural anesthetic. The client’s fundus is firm and midline atthe level of the umbilicus, lochia is moderate, and the bladder is not palpable. At this time, inaddition to this information, it is essential that the nurse also assess the client for:1)A)Any signs of beginning postpartum depression.B)Teaching needs about the newborn prior to discharge.C)Teaching needs prior to discharge.D)A negative or positive Homan’s sign.Answer:DExplanation:A)The postpartum client whose legs have been in stirrups for a period of time is atrisk for venous thrombosis in the lower extremities, because of increased pressureon the calves of the legs. The client has also been in bed for a period of time whilein labor. Assessing for the presence of Homan’s sign, and any warmth, redness,and swelling in the calf areas is part of the expected assessment of this client.Postpartum depression does not onset this early after delivery. However, the nursemust be attentive to the client’s comments. Teaching needs should be identifiedand addressed prior to the client’s discharge. It will not take priority overassessment for a possible physiological complication.AssessmentPhysiological Integrity-Physiological AdaptationApplicationB)The postpartum client whose legs have been in stirrups for a period of time is atrisk for venous thrombosis in the lower extremities, because of increased pressureon the calves of the legs. The client has also been in bed for a period of time whilein labor. Assessing for the presence of Homan’s sign, and any warmth, redness,and swelling in the calf areas is part of the expected assessment of this client.Postpartum depression does not onset this early after delivery. However, the nursemust be attentive to the client’s comments. Teaching needs should be identifiedand addressed prior to the client’s discharge. It will not take priority overassessment for a possible physiological complication.AssessmentPhysiological Integrity-Physiological AdaptationApplicationC)The postpartum client whose legs have been in stirrups for a period of time is atrisk for venous thrombosis in the lower extremities, because of increased pressureon the calves of the legs. The client has also been in bed for a period of time whilein labor. Assessing for the presence of Homan’s sign, and any warmth, redness,and swelling in the calf areas is part of the expected assessment of this client.Postpartum depression does not onset this early after delivery. However, the nursemust be attentive to the client’s comments. Teaching needs should be identifiedand addressed prior to the client’s discharge. It will not take priority overassessment for a possible physiological complication.AssessmentPhysiological Integrity-Physiological AdaptationApplication1
D)The postpartum client whose legs have been in stirrups for a period of time is atrisk for venous thrombosis in the lower extremities, because of increased pressureon the calves of the legs. The client has also been in bed for a period of time whilein labor. Assessing for the presence of Homan’s sign, and any warmth, redness,and swelling in the calf areas is part of the expected assessment of this client.Postpartum depression does not onset this early after delivery. However, the nursemust be attentive to the client’s comments. Teaching needs should be identifiedand addressed prior to the client’s discharge. It will not take priority overassessment for a possible physiological complication.AssessmentPhysiological Integrity-Physiological AdaptationApplication2)A toddler is being seen in an urgent care clinic for a cut on the forehead which occurred when thechild fell while running. The cut may require some stitches. A nurse is obtaining vital signmeasurements prior to the child being seen by the physician. The nurse observes that the child’sabdomen has a “pot belly” appearance. The nurse considers this observation to most likely indicatethat:2)A)This is an expected finding for a child of this age.B)The child may need to be screened for scoliosis and lordosis.C)The child may be overweight and a dietary assessment should be done.D)The child may be under-or malnourished and a dietary assessment should be done.Answer:AExplanation:A)A “pot belly” appearance of the abdomen is normal for a child from birth to around5 years of age. In assessing the overall appearance of the toddler, the nurse shouldlook for any other indications of nutritional causes for this, such as very thinextremities and face, or excess weight throughout the body. Children of this ageoften have an exaggerated lordosis, which will become less prominent as the childdevelops. Screening for these two conditions is usually started at a later age.AssessmentHealth Promotion and MaintenanceApplicationB)A “pot belly” appearance of the abdomen is normal for a child from birth to around5 years of age. In assessing the overall appearance of the toddler, the nurse shouldlook for any other indications of nutritional causes for this, such as very thinextremities and face, or excess weight throughout the body. Children of this ageoften have an exaggerated lordosis, which will become less prominent as the childdevelops. Screening for these two conditions is usually started at a later age.AssessmentHealth Promotion and MaintenanceApplicationC)A “pot belly” appearance of the abdomen is normal for a child from birth to around5 years of age. In assessing the overall appearance of the toddler, the nurse shouldlook for any other indications of nutritional causes for this, such as very thinextremities and face, or excess weight throughout the body. Children of this ageoften have an exaggerated lordosis, which will become less prominent as the childdevelops. Screening for these two conditions is usually started at a later age.AssessmentHealth Promotion and MaintenanceApplication2
D)A “pot belly” appearance of the abdomen is normal for a child from birth to around5 years of age. In assessing the overall appearance of the toddler, the nurse shouldlook for any other indications of nutritional causes for this, such as very thinextremities and face, or excess weight throughout the body. Children of this ageoften have an exaggerated lordosis, which will become less prominent as the childdevelops. Screening for these two conditions is usually started at a later age.AssessmentHealth Promotion and MaintenanceApplication3)An elderly client is being seen at a city health clinic for a routine appointment with her nursepractitioner for an examination, medication review, and lab requests that might be indicated. Theclient has long-standing congestive heart failure that has been well-controlled with digoxin(Lanoxin), furosemide (Lasix), and a low-sodium diet. She tells the LPN/LVN that she is feelingwell and has been doing her usual activities. The nurse should most appropriately plan to next:3)A)Inform the nurse practitioner that the client is getting ready to be seen.B)Have the client change into a gown.C)Ask the client if she would like to use the bathroom.D)Obtain the client’s height and weight, vital signs, and any presence of pain.Answer:CExplanation:A)The client is elderly and takes a diuretic. The wait to see the nurse practitioner canbe of any length, plus the time for the exam and discussion. The client may bereluctant to ask. Obtaining the client’s height and weight, vital signs, and presenceof pain, having the client change into a gown, and informing the nurse practitionerthat the client is getting ready to be seen focus on the tasks to be done as part of thevisit and should not take priority over the client’s needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisB)The client is elderly and takes a diuretic. The wait to see the nurse practitioner canbe of any length, plus the time for the exam and discussion. The client may bereluctant to ask. Obtaining the client’s height and weight, vital signs, and presenceof pain, having the client change into a gown, and informing the nurse practitionerthat the client is getting ready to be seen focus on the tasks to be done as part of thevisit and should not take priority over the client’s needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisC)The client is elderly and takes a diuretic. The wait to see the nurse practitioner canbe of any length, plus the time for the exam and discussion. The client may bereluctant to ask. Obtaining the client’s height and weight, vital signs, and presenceof pain, having the client change into a gown, and informing the nurse practitionerthat the client is getting ready to be seen focus on the tasks to be done as part of thevisit and should not take priority over the client’s needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis3
D)The client is elderly and takes a diuretic. The wait to see the nurse practitioner canbe of any length, plus the time for the exam and discussion. The client may bereluctant to ask. Obtaining the client’s height and weight, vital signs, and presenceof pain, having the client change into a gown, and informing the nurse practitionerthat the client is getting ready to be seen focus on the tasks to be done as part of thevisit and should not take priority over the client’s needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis