Chapter 28 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 28 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: SEQ

The nurse uses the nursing process to create a plan of care for a hospitalized client. Rank the activities of the nursing process in the proper order.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

1. The nurse educates the client regarding the care of his sternal and leg incisions.
2. The client arrives at the hospital with chest pain. The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft.
3. The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection.
4. The nurse develops a plan to help prevent some of the known complications associated with surgery.

Correct Answer: 2, 3, 4, 1

Rationale 1: The fourth step is to implement nursing interventions that are based on the developed plan. The last step is to evaluate how well the nurse’s plan for the client worked.

Rationale 2: The steps of the nursing process begin with the assessment phase. The nurse assesses the objective and subjective information about the client.

Rationale 3: The second step is to create a nursing diagnosis using NANDA nursing labels.

Rationale 4: The third step is to develop a plan to help the client heal and prevent the development of complications.

Global Rationale: The steps of the nursing process begin with the assessment phase. The nurse assesses the objective and subjective information about the client. The second step is to create a nursing diagnosis using NANDA nursing labels. The third step is to develop a plan to help the client heal and prevent the development of complications. The fourth step is to implement nursing interventions that are based on the developed plan. The last step is to evaluate how well the nurse’s plan for the client worked.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

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: Assessment

Learning Outcome: 28.1: Differentiate the types of assessment carried out with the hospitalized patient.

MNL Learning Outcome:

Page Number: p. 854

 

Question 2

Type: MCMA

The nurse works on a medical-surgical unit. Which clients will require a rapid assessment?

Standard Text: Select all that apply.

1. The client had an open appendectomy 2 days ago and is preparing to be discharged today.
2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia.
3. The client has just been received from the Post Anesthesia Care Unit.
4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse.
5. The client begins to complain of difficulty breathing. The client’s oxygen saturation level has decreased from 93% on room air this morning to 87%.

Correct Answer: 3, 4, 5

Rationale 1: The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment.

Rationale 2: The client who has been admitted to the unit the day before and is receiving effective treatment requires a routine assessment.

Rationale 3: The nurse should perform a rapid assessment on a client following a surgical procedure.

Rationale 4: The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care.

Rationale 5: The nurse should perform a rapid assessment on a client who is in distress.

Global Rationale: The nurse should perform a rapid assessment on a client following a surgical procedure. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care. The nurse should perform a rapid assessment on a client who is in distress. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment. The client who has been admitted to the unit the day before requires a routine assessment.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: Assessment

Learning Outcome: 28.1: Differentiate the types of assessment carried out with the hospitalized patient.

MNL Learning Outcome:

Page Number: pp. 854–855

 

Question 3

Type: MCSA

The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes. Which statement by the student nurse indicates that further education is required?

1. “The rapid assessment should last approximately 10 minutes.”
2. “I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care.”
3. “The rapid assessment will help me establish baseline data about the client.”
4. “After I perform the rapid assessments on the clients I’ve been assigned, I can go back and get more information during my routine assessments.”

Correct Answer: 1

Rationale 1: The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes.

Rationale 2: It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients.

Rationale 3: The rapid assessment helps the nurse establish baseline data about the client.

Rationale 4: Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client.

Global Rationale: The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes. It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients. The rapid assessment helps the nurse establish baseline data about the client. Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: Assessment

Learning Outcome: 28.1: Differentiate the types of assessment carried out with the hospitalized patient.

MNL Learning Outcome:

Page Number: p. 854