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Clinical Pocket Guide for Health & Physical Assessment in Nursing 3rd Edition TEST BANK
Clinical Pocket Guide for Health & Physical Assessment in Nursing 3rd Edition TEST BANK
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,D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/eChapter 1
Question 1
Type: MCSA
While conducting a health history, a client states, “I am healthy, I don’t know why I have to be
here to get a check-up.” However, the client reports, type 2 diabetes mellitus and an unhealed
ulcer on the left foot. Based on this information, which statement by the nurse is the most
appropriate?
1. “I feel that you are in denial about your health status.”
2. “Tell me about your definition of being healthy.”
3. “Do you understand what diabetes is?”
4. “Is there anything else you are not telling me?”
Correct Answer: 2
Rationale 1: More information would be needed before the nurse could attribute the client’s
viewpoint as denial or lack of knowledge.
Rationale 2: A client will have his or her own definition of health, illness, and wellness. The
individual’s concept of health and wellness is influenced by many factors, including age, gender,
race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and
self-expectations.
Rationale 3: The client’s history of type 2 diabetes is a valid area requiring further investigation
but the nurse must first ascertain the client’s definition of healthy.
Rationale 4: There is not enough information to determine the client’s withholding of
information to the nurse.
Global Rationale: A client will have his or her own definition of health, illness, and wellness.
The individual’s concept of health and wellness is influenced by many factors, including age,
gender, race, family, culture, religion, socioeconomic conditions, environment, previous
experiences, and self-expectations. More information would be needed before the nurse could
attribute the client’s viewpoint as denial or lack of knowledge. The client’s history of type 2
diabetes is a valid area requiring further investigation but the nurse must first ascertain the
client’s definition of healthy. There is also not enough information to determine the client’s
withholding of information to the nurse.
Cognitive Level: Analyzing
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: Personal and Professional Development: Identify problems; Contribute to
assessment of outcome achievement.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the key components of health assessment in nursing.
MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history
interview of a client.
Page Number: p. 3
,Question 2
Type: MCSA
Which information would the nurse include in the assessment category when using SOAP to
documents in the medical record?
1. The client’s blood pressure was 177/93.
2. The recent loss of employment and insurance has prevented the client from being able to
afford prescription medications.
3. The client reports having lost her job and insurance 3 months ago.
4. Referrals have been made to social services to determine financial assistance programs
available.
Correct Answer: 2
Rationale 1: This is the “O” component; objective data.
Rationale 2: The “A” component of the SOAP note refers to conclusions drawn from the
subjective and objective data obtained.
Rationale 3: This is subjective data (“S” component).
Rationale 4: This is the “P” component, plan.
Global Rationale: The “A” component of the SOAP note refers to conclusions drawn from the
subjective and objective data obtained. The client’s recent loss of employment and the potential
that this was a contributing factor in the inability to afford medications is an example of a
conclusion. The client’s reported blood pressure would be an example of objective data.
Objective data is information that can be measured by the examiner. Blood pressure is not an
example of subjective information nor is it a conclusion. The client’s reported loss of
employment and insurance is an example of subjective data. The statement does not include
conclusions as to the results of these events. Making referrals to social services is an example of
an intervention. It is not a conclusion.
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: Personal and Professional Development: Identify problems; Contribute to
assessment of outcome achievement.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the key components of health assessment in nursing.
MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history
interview of a client.
Page Number: pp. 5–8
Question 3
Type: MCSA
, The nurse is conducting a workshop on wellness and health promotion using the initiatives of
Healthy People 2020. After the session, which statement by a participant indicates an
understanding of the initiatives?
1. “It will allow health care providers to lobby legislators for more funding.”
2. “The primary goal of Healthy People 2020 is to assist health care providers in determining
risk factors for premature birth.”
3. “Healthy People 2020 seeks to promote health, prevent illness, disability, and premature
death.”
4. “The initiatives will outline standards of care for providers in managing diseases.”
Correct Answer: 3
Rationale 1: Health care providers and other persons interested in programs to promote health
have found the document to be a useful source of information in their efforts to gain funding.
Rationale 2: The Healthy People 2020 initiative is a 10-year strategy intended to promote
health, prevent illness, disability, and premature death. The document identifies leading health
indicators that reflect public health concerns. Risk factors for premature birth may be part of
those health indicators, but the scope of the document covers broad areas of concern.
Rationale 3: The Healthy People 2020 initiative is a 10-year strategy intended to promote
health, prevent illness, disability, and premature death.
Rationale 4: Standards of care in disease management is not a component of the document.
Global Rationale: The Healthy People 2020 initiative is a 10-year strategy intended to promote
health, prevent illness, disability, and premature death. The document identifies leading health
indicators that reflect public health concerns. Risk factors for premature birth may be part of
those health indicators, but the scope of the document covers broad areas of concern. Health care
providers and other persons interested in programs to promote health have found the document to
be a useful source of information in their efforts to gain funding. Standards of care in disease
management are not a component of the document.
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: VII.1. Assess protective and predictive factors, including
genetics, which influence the health of individuals, families, groups, communities and
populations.
NLN Competencies: Knowledge and Practice: Health promotion/disease prevention.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.2: Relate the goals and objectives of Healthy People 2020 to health
assessment in nursing.
MNL Learning Outcome:
Page Number: pp. 2–3
Question 4
Type: MCSA
The nurse is developing a handout for clients in a healthcare provider’s office. The nurse
includes which focus area in this handout to emphasize current changes in the health care
delivery system?
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