Chapter 22 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 22 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: MCSA

The nurse is interviewing an older adult client in the clinic who reports incontinence. Numerous attempts in the recent past have been unsuccessful in helping to control the problem. Which is the priority diagnosis for this client?

1. Skin integrity impairment.
2. Self-care deficit.
3. Self-esteem, situational-low.
4. Infection.

Correct Answer: 3

Rationale 1: Skin integrity impairment is of concern, but there is no data in this scenario to indicate that it is the highest priority nursing diagnosis.

Rationale 2: There is no data in this situation to indicate any self-care deficit issues.

Rationale 3: Since the client has had no success in controlling the incontinence after repeated attempts, this client is at a high risk for situational low self-esteem.

Rationale 4: There is no data in this scenario to indicate a risk for infection.

Global Rationale: Clients suffering from incontinence are at increased risk for social isolation, self-esteem disturbance, and other psychosocial problems. There is no data to support a self-care deficit; the information available is that this client has tried to implement measures to treat the problem. The client is certainly at risk for infection and skin integrity impairment, but these two are not active at this time.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care.

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: Diagnosis

Learning Outcome: 22.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 13.1.3; 14.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 581

Question 2

Type: MCMA

The nurse is interviewing a client regarding urinary health. Which response would the nurse include during the collection of subjective data?

Standard Text: Select all that apply.

1. “Do you have difficulty starting your stream of urine?”
2. “After you urinate, does your bladder feel full or empty?”
3. “Do you ever have an accident or wet yourself when you sneeze?”
4. “Do you have to hurry to the bathroom when you have to urinate?”
5. “Your recent urinalysis reveals protein in the urine.”

Correct Answer: 1, 2, 3, 4

Rationale 1: Difficulty starting a stream usually indicates prostate disease in the male client.

Rationale 2: Urinary retention, or holding residual urine in the bladder after voiding, creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection.

Rationale 3: Stress incontinence is most likely the cause of the client experiencing partial or complete incontinence when sneezing, coughing, and laughing due to loss of muscle control.

Rationale 4: Urge incontinence is most likely the cause of the client experiencing partial or complete incontinence if the client is consistently unable to reach the bathroom in time, and is due to loss of muscle control.

Rationale 5: This is an example of objective data, not subjective data.

Global Rationale: Urinary retention or holding residual urine in the bladder after voiding creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection. Difficulty starting a stream usually indicates prostate disease in the male client. Stress incontinence and urgency occur when there is loss of muscle control over urination. Telling the client the results of the recent urinalysis is an example of objective data.

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: 22.3: Develop questions to be used when completing the focused interview.

MNL Learning Outcome: 13.1.2; 14.1.2. Plan questions to consider when the nurse performs a focused interview during physical assessment.

Page Number: p. 582

Question 3

Type: MCSA

The nurse is collecting a urine specimen from a client and notes the urine is foamy and amber in color. Based on this data, which diagnosis would the nurse suspect?

1. Kidney stones.
2. Urinary tract infection.
3. Prostate disease.
4. Liver disease.

Correct Answer: 4

Rationale 1: Pain is the primary symptom for the client with kidney stones. The pain may radiate and is variable in location and severity. Other symptoms include spasms, nausea, vomiting, pain on urination, frequency and urgency of urination, and gross hematuria.

Rationale 2: If a urinary tract infection is present, the client may complain of pain during urination with urgency, frequency, dribbling, pain upon urination, and suprapubic or lower back pain. Hematuria, as well as cloudy and foul-smelling urine may also accompany a urinary tract infection.

Rationale 3: Prostate disease may make it difficult for male clients to begin or maintain their urine stream.

Rationale 4: Foamy, amber-colored urine frequently is an indication of hepatic illness (liver disease).

Global Rationale: Foamy, amber-colored urine may indicate the presence of hepatic illness (liver disease). Pain is the primary symptom for the client with kidney stones. The pain may radiate and is variable in location and severity. Other symptoms include spasms, nausea, vomiting, pain on urination, frequency and urgency of urination, and gross hematuria. If a urinary tract infection is present, the client may complain of pain during urination with urgency, frequency, dribbling, pain upon urination, and suprapubic or lower back pain. Hematuria, as well as cloudy and foul-smelling urine may also accompany a urinary tract infection. Prostate disease may make it difficult for male clients to begin or maintain their urine stream.

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: Evaluation

Learning Outcome: 22.6: Differentiate normal from abnormal findings in physical assessment of the urinary system.

MNL Learning Outcome: 13.2.1; 14.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 600