EssentialHealthAssessment2ndE ditionThompsonTestB ank v v
Chapter1.UnderstandingHealth Assessment v
Question 1 v
v Type:MCSA
Thenurseisobtainingahealthhistoryfromaclientwhoreportsthatheishealthyandhasnohealth
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concerns.Aspartofthehealthhistory,thenursedocumentsthattheclientreportedthathehashigh
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v bloodpressureandsuffers fromalegulcerthatremainsunhealedafter6months.Whichofthe
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v followingstatementswouldbethebestchoiceforthenursetouseatthispointintheinterview?
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1. Ifeelthatyoumaybeindenialaboutyourhealthstatus.
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2. Tellmeabout yourdefinitionofbeinghealthy. v
3. Doyouunderstandwhathypertensionis? v
4. Isthereanythingelseyou arenottellingme? v
CorrectAnswer:2
Rationale1:Moreinformationwouldbeneeded beforethenursecouldattributetheclientsviewpoint
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v asdenialorlackofknowledge.
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Rationale2:Aclient will havehisorherowndefinitionofhealth,illness,and wellness.The
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v individualsconceptofhealth and wellness isinfluenced bymanyfactors,including age,gender, v v v
v race,family,culture,religion,socioeconomicconditions,environment,previousexperiences,and
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v self-expectations.
Rationale3:The clientshistoryofhypertensionisavalidarea requiring furtherinvestigationbutthe
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v nursemustfirstascertaintheclientsdefinitionofhealthy.
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,Rationale4:Thereisnote noughinformationtodeterminetheclientswithholdingofinformation v v v v v v v v vv v v
to the nurse.
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GlobalRationale:Aclientwillhavehisorherowndefinitionofhealth,illness,andwellness.The
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v individualsconceptofhealthandwellnessisinfluencedbymanyfactors,includingage,gender, race,
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family,culture,religion,socioeconomicconditions,environment,previousexperiences,andself-
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expectations.More informationwouldbeneededbeforethenurse couldattributetheclients
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v viewpointasdenialorlack ofknowledge.Theclientshistoryofhypertensionisa validarearequiring v v v v v
v furtherinvestigationbutthenursemustfirstascertaintheclientsdefinitionofhealthy.Thereisalso
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v notenoughinformationtodeterminetheclientswithholdingofinformationtothenurse. v v v v
CognitiveLevel:Analyzing v v
ClientN vvvvvvvvvvvvvvv v eed:HealthPromotion andMaintenance v v
Client NeedSub: v
Nursing/IntegratedConcepts: NursingProcess: Assessment v v
v LearningOutcome:1.4:Identifythefactors toconsiderinhealth assessment v v v
v Question2 v
Type:MCSA
Thenurseisdocumentingintheclientsmedicalrecordandwishes touseSOAPcharting.Thenurse v v v v v v v
v includeswhichofthefollowingundertheassessmentcategory?
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1. Theclientsblood pressurewas177/93. v v
2. Therecent loss ofemploymentandinsurancehave preventedtheclient from being ableto
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v affordprescriptionmedications.
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3. Theclient reportshavinglostherjobandinsurance3months ago.
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,4. Referralshavebeen madetosocialservicestodeterminefinancialassistanceprograms
v v v v
v available.
CorrectAnswer:2
v Rationale1:ThisistheOcomponent,objectivedata. v
Rationale2:TheAcomponentoftheSOAPnoterefers toconclusionsdrawnfrom thesubjective v v v v
v andobjectivedataobtained.
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Rationale3:Thisissubjectivedata.
v Rationale4:ThisisthePcomponent,plan. v
Global Rationale: TheAcomponentofthe SOAPnotereferstoconclusionsdrawnfrom the
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v subjectiveandobjectivedataobtained.Theclientsrecentlossofemploymentandthep otentialthat v v v vvvvvvvvvvv v
v thiswasacontributingfactorintheinabilitytoaffordmedicationsisanexampleofaconclusion.The
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clientsreportedbloodpressurewouldbeanexampleofobjectivedata.
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Objective data is information that can be measured by the examiner. Blood pressure is not an
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v exampleofsubjective information norisitaconclusion.Theclients reported lossofemploymentand
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v insuranceisanexampleofsubjectivedata.The statement doesnotincludeconclusionsas totheresults v v v v
v oftheseevents.Makingreferralsto socialservicesisanexampleofan intervention.Itisnota
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v conclusion.
Cognitive Level: Applying v v
v ClientNeed:HealthPromotion andMaintenance
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v Client NeedSub:
v
Nursing/IntegratedConcepts:Nursing Process:Assessment v v
v LearningOutcome:1.4:Identifythefactors toconsiderinhealth assessment. v v v
v Question3 v
Type:MCSA
, The nurse is presenting a workshop on wellness and health promotion and the initiatives of
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Healthy People 2020 as a resource for this topic. After the session, which of the following
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statements bya participant indicates an understandingconcerningtheinitiativesproposed?
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1. Itwillallowhealth careproviderstolobbylegislatorsformore funding. v v v
2. TheprimarygoalofHealthyPeople2020istoassisthealthcareprovidersindeterminingrisk v
v factorsforprematurebirth.
v v
3. HealthyPeople2020seekstopromoteshealth,prevent illness,disability,andpremature death. v v v v
4. Theinitiatives willoutlinestandardsofcareforprovidersin managingdiseases. v v
CorrectAnswer:3
Rationale1:Healthcareproviders and otherpersonsinterested in programstopromotehealthhave v v v v v
v foundthedocumenttobeausefulsourceofinformationintheireffortstogainfunding.
Rationale2:TheHealthyPeople2020initiativeisa10-yearstrategyintendedtopromotehealth,
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v preventillness,disability,andprematuredeath.Thedocumentidentifiesleadinghealthindicators that
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v reflectpublichealthconcerns. Riskfactorsforprematurebirthmaybepartof those health v v v
v indicators,butthescopeofthedocumentcoversbroadareasofconcern.
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Rationale3:TheHealthyPeople2020initiativeisa10-yearstrategyintendedtopromotehealth,prevent v v
v illness,disability,andprematuredeath.
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Rationale4:Standardsofcareindiseasemanagementis notacomponentofthedocument. v v
Global Rationale:TheHealthyPeople2020initiativeisa10-yearstrategyintended topromote
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v health,preventillness,disability,andprematuredeath.Thedocumentidentifiesleadinghealth
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v indicatorsthatreflectpublichealthconcerns.Riskfactorsforprematurebirthmaybepartofthose
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healthindicators,but thescopeof thedocument coversbroadareasofconcern.Health care providers
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v andotherpersonsinterestedinprogramstopromotehealthhavefoundthedocument tobeauseful v v v v v v v v
v sourceofinformationintheireffortstogainfunding.Standardsofcareindiseasemanagementis nota
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componentofthedocument.
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