Chapter 27 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 27 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

A pregnant client reports concern about the development of reddish marks on her abdomen and breasts. The client asks about having a cream prescribed to help them disappear. Which information will the nurse include when providing education to the client regarding this inquiry?

Standard Text: Select all that apply.

1. The stretch marks will fade but not disappear.
2. Cream will help the skin stay supple.
3. Cocoa butter lotions and creams will clear the marks completely.
4. The marks will lighten to a silvery tone after pregnancy.
5. Wearing supportive undergarments will help to support the skin and reduce the appearance of the marks.

Correct Answer: 1, 2, 4

Rationale 1: Striae gravidarum are known as stretch marks. They commonly occur during pregnancy, and result from the stretching of the skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after the pregnancy ends.

Rationale 2: There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple.

Rationale 3: These marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple.

Rationale 4: These marks will not disappear but will fade and lighten after the pregnancy ends.

Rationale 5: Wearing supportive undergarments will help promote comfort to the growing abdomen but will not prevent the development of stretch marks.

Global Rationale: Striae gravidarum are known as stretch marks. They commonly occur during pregnancy, and result from the stretching of the skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple. Wearing supportive undergarments will help promote comfort to the growing abdomen but will not prevent the development of stretch marks.

Cognitive Level: Applying

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: 27.1: Describe the anatomy and physiology specific to assessment of the pregnant and postpartum female.

MNL Learning Outcome:

Page Number: pp. 801–802

 

Question 2

Type: MCSA

A client who is 38 weeks pregnant reports increased urinary frequency. Based on this data, which response by the nurse is indicated?

1. “Your reports are consistent with a urinary tract infection.”
2. “I will need to check your blood sugar as excessive urination is associated with gestational diabetes.”
3. “Reducing your fluid intake will be helpful to manage this problem.”
4. “This is normal occurrence in the later stages of pregnancy.”

Correct Answer: 4

Rationale 1: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has a urinary tract infection.

Rationale 2: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has an elevation in blood glucose levels.

Rationale 3: The health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an increased oral fluid intake.

Rationale 4: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence.

Global Rationale: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has an elevation in blood glucose levels or a urinary tract infection. The health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an increased oral fluid intake.

Cognitive Level: Applying

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: 27.1: Describe the anatomy and physiology specific to assessment of the pregnant and postpartum female.

MNL Learning Outcome:

Page Number: pp. 802–803

 

Question 3

Type: MCSA

While reviewing a pregnant client’s medical record, the nurse notes that the cervix was soft in texture and nontender during the pelvic examination. Based on this data, which would the nurse identify as a normal finding?

1. Piskacek sign.
2. Goodell sign.
3. Chadwick sign.
4. Hegar sign.

Correct Answer: 2

Rationale 1: Piskacek sign is when the shape of the uterus becomes irregular due to the implantation of the ovum.

Rationale 2: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell sign.

Rationale 3: Chadwick sign is the appearance of a bluish-purple coloration of the cervix due to vascular congestion.

Rationale 4: Hegar sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix.

Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell sign. Chadwick sign, also occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Piskacek sign is when the shape of the uterus becomes irregular due to the implantation of the ovum. Hegar sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix.

Cognitive Level: Applying

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: Evaluation

Learning Outcome: 27.1: Describe the anatomy and physiology specific to assessment of the pregnant and postpartum female.

MNL Learning Outcome:

Page Number: p. 841