Chapter 20 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 20 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

A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures. Which response by the nurse is the most appropriate?

1. “Your lymph nodes filter blood for your body.”
2. “They are responsible for the break down of old red blood cells.”
3. “They make lymphocytes for you.”
4. “Your lymph nodes help to remove infectious organisms.”

Correct Answer: 4

Rationale 1: Lymph nodes actually filter lymph fluid before returning it to the client’s blood.

Rationale 2: The liver is responsible for breaking down old red blood cells.

Rationale 3: Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it the blood.

Rationale 4: This statement is accurate. The lymph fluid is filtered in the lymph node to remove pathogens before returning it the bloodstream.

Global Rationale: The lymph fluid is filtered in the lymph node to remove pathogens before returning it the bloodstream. The liver is responsible for breaking down old red blood cells. Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it the blood.

Cognitive Level: Understanding

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: Implementation

Learning Outcome: 20.1: Describe the anatomy and physiology of the peripheral vascular and lymphatic systems.

MNL Learning Outcome: 3.1.1; 7.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 502

Question 3

Type: MCMA

The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins. Which statements by the client will the nurse document as risk factors for varicose vein development?

Standard Text: Select all that apply.

1. “My mother had big veins on her legs from the time I was little.”
2. “My father is of Japanese descent.”
3. “I’m a hair stylist.”
4. “I was pregnant once and have a son.”
5. “I know I weigh a lot more than I should.”

Correct Answer: 1, 3, 4, 5

Rationale 1: A client who has a family history of varicose veins has an increased risk for developing them.

Rationale 2: Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins.

Rationale 3: Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins.

Rationale 4: People who have been pregnant multiple times have an increased risk for developing varicose veins.

Rationale 5: People who are obese have an increased risk for developing varicose veins.

Global Rationale: A client who has a family history of varicose veins has an increased risk for developing them. Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins. People who have been pregnant multiple times have an increased risk for developing varicose veins. People who are obese have an increased risk for developing varicose veins. Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: 20.2: Develop questions that guide the focused interview.

MNL Learning Outcome: 3.1.2; 7.1.3. Plan questions to consider when the nurse performs a focused interview during physical assessment.

Page Number: pp. 503–504

Question 4

Type: MCMA

While performing a focused interview with a healthy adult client, the nurse notes frequent position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech. The vital signs are BP 160/88 mmHg, apical pulse 102 beats per minute, respiratory rate 26 per minute. Which responses by the nurse are appropriate in this situation?

Standard Text: Select all that apply.

1. “I’m going to take your temperature now.”
2. “Have you ever experienced chest pain?”
3. “Are you feeling any anxiety right now?”
4. “Are you experiencing any pain at this time?”
5. “Have you ever been diagnosed with hypothyroidism?”

Correct Answer: 2, 3, 4

Rationale 1: It will be appropriate to assess the client’s temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety.

Rationale 2: The client’s actions may indicate that the client is experiencing pain. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview.

Rationale 3: The client’s actions are consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate.

Rationale 4: The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview.

Rationale 5: The client’s vital signs and actions are more likely associated with hyperthyroidism.

Global Rationale: The client’s actions may indicate that the client is experiencing pain. The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview. The client’s actions are also consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate. It will be appropriate to assess the client’s temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety. The client’s vital signs and actions are more likely associated with hyperthyroidism.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

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: 20.2: Develop questions that guide the focused interview.

MNL Learning Outcome: 3.1.2; 7.1.3. Plan questions to consider when the nurse performs a focused interview during physical assessment.

Page Number: pp. 504–508