Module 34 Assessment

Module 34   Assessment

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

The Concept of Assessment

1) The nurse in the clinic is assessing a 60-year-old client who has 2+ ankle edema, crackles throughout the lung fields, and dyspnea on exertion. The nurse concludes that the client will need lifestyle-change teaching and asks:

1. A) About the client’s family history.
2. B) If the client eats foods high in salt.
3. C) How many children the client has.
4. D) If the client is married or divorced.

Answer:  B

Explanation:  A) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client’s lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client’s current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client’s current lifestyle.

1. B) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client’s lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client’s current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client’s current lifestyle.
2. C) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client’s lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client’s current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client’s current lifestyle.
3. D) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client’s lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client’s current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client’s current lifestyle.

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Cognitive Level:  Creating

Client Need:  Physiological Integrity

Nursing Process:  Assessment

Learning Outcome:  2. Relate the purposes of conducting a physical examination.

2) The nurse is preparing to assess a client who has chronic obstructive pulmonary disease (COPD). The client is currently experiencing difficulty breathing. Before palpating the client’s abdomen, the nurse takes which action?

1. A) Administer 6 L of oxygen first.
2. B) Have the client remain upright.
3. C) Have the client assume the modified Sims position.
4. D) Have the client bend over a table.

Answer:  B

Explanation:  A) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client’s ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD

1. B) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client’s ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD
2. C) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client’s ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD
3. D) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client’s ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD

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Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  3. Propose actions required when preparing to conduct a physical examination.

3) The nurse is preparing to conduct a physical examination of a client’s head and neck area. The client is in a wheelchair due to a C3-C4 spine injury. The nurse recognizes that the client should be:

1. A) Supported during the examination.
2. B) Placed in an armless regular chair.
3. C) Placed in a Sims position.
4. D) Placed supine for the examination.

Answer:  A

Explanation:  A) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.

1. B) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.
2. C) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.
3. D) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.

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Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  4. Discriminate among positions appropriate for examination of different areas of the body.

4) A client is complaining of pain in the lower-left quadrant of the abdomen. The nurse prepares to percuss the abdomen and notes that the client has a great deal of hair on the lower abdomen. The nurse should:

1. A) Moisten the abdominal hair.
2. B) Document that the client has hirsutism.
3. C) Cut the client’s hair over the entire abdomen.
4. D) Discontinue using percussion, palpate only.

Answer:  A

Explanation:  A) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client’s hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.

1. B) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client’s hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.
2. C) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client’s hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.
3. D) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client’s hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.

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Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Assessment

Learning Outcome:  5. Demonstrate use of each method of examination: inspection, palpation, percussion, and auscultation.

5) The nurse is examining a client with congestive heart failure who takes propranolol and furosemide. The client complains of fatigue and an inability to finish tasks. The nurse determines which of the following?

1. A) The medication needs adjustment.
2. B) The client has not been exercising.
3. C) The client is experiencing expected manifestations of CHF.
4. D) The client should be hospitalized.

Answer:  C

Explanation:  A) Heart failure and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with heart failure. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.

1. B) Heart failure and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with heart failure. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.
2. C) Heart failure and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with heart failure. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.
3. D) Heart failure and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with heart failure. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.

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Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Assessment

Learning Outcome:  6. Discuss factors required to properly interpret findings from the nursing assessment.