Health Assessment For Nursing Practice 5th Edition by Wilson
Health Assessment For Nursing Practice 5th Edition by Wilson
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Chapter 23: Documenting the Head-to-Toe Health Assessment
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | Heart sounds normal. |
| b. | Few ectopic beats heard during auscultation. |
| c. | S1 murmur is heard at second right sternal border. |
| d. | Pulse within normal limits. |
ANS: C
| Feedback | |
| A | This information is not specific without a description of what is considered “within normal limits” for hair color, texture, length, etc. |
| B | This description is not specific because the number of permanent teeth is not detailed. |
| C | This is the most descriptive data, specifying what is heard and the location. |
| D | This description would be more descriptive if the pain scale were used to indicate the level of tenderness and if the location on the abdomen were documented. |
DIF: Cognitive Level: Apply REF: 540
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
| a. | Heart sounds normal. |
| b. | Few ectopic beats heard during auscultation. |
| c. | Apical pulse palpated at 5th left intercostal space, midclavicular line |
| d. | Pulse within normal limits. |
ANS: D
| Feedback | |
| A | This information is not specific without a description of what is considered “within normal limits” for heart sounds |
| B | This description is not specific |
| C | This is the most descriptive data, specifying what is heard and the location. |
| D | This description would be more descriptive such as which pulse and the rate |
DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
| a. | Chronic diseases |
| b. | Immunizations received |
| c. | Allergies to medications or food |
| d. | Causes of death of the patient’s parents |
ANS: B
| Feedback | |
| A | Chronic diseases are documented under the present health status category. |
| B | Immunizations are documented under the past health history category. |
| C | Allergies to medications or food are documented under the present health status category. |
| D | Causes of death of parents are documented under the family history category. |
DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
| a. | Review of systems |
| b. | Present health status |
| c. | Past health history |
| d. | Functional ability |
ANS: A
| Feedback | |
| A | In the review systems part of the history, the nurse asks patients whether they have had symptoms from specific body systems. Patients either deny or admit to having the symptoms. |
| B | The present health status category contains data on chronic diseases, medications, and allergies. |
| C | The past health history category contains data on childhood diseases, surgeries and hospitalizations, and immunizations. |
| D | The functional ability category contains data on patient’s activities, including maintaining a home and working full-time. |
DIF: Cognitive Level: Understand REF: 539
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
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