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Health & Physical Assessment in Nursing, 1st Canad
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Voorbeeld van de inhoud
,Chapter 1
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the
question.
1) A nurse is obtaining a health history from a client who reports that he is healthy and has no health
concerns. As part of the health history, the nurse documents that the client reported that he has high
blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. What is the most
appropriate response by the nurse at this point in the interview?
1) “I feel that you may be in denial about your health status.”
2) “Tell me about your definition of being healthy.”
3) “Do you understand what hypertension is?”
4) “Is there anything else you are not telling me?”
1) 2
Explanation:
1. More information is needed before the nurse could describe the client’s viewpoint as denial.
2. A client will have his or her own definition of health, illness, and wellness that is influenced by
many factors including age, gender, race, family, culture, religion, socioeconomic conditions,
environment, previous experiences, and self-expectations. It is important for the nurse to understand
the client’s perspective on health.
3. More information is needed before the nurse can determine that the client has a lack of knowledge.
4. There is not enough information to determine that the client is withholding information from the
nurse. Also this statement could come across as the nurse accusing the client.
Assessment
Analysis
Objective 1
Page 4
Difficulty - 1
2) What is the best description of the assessment component of SOAP charting?
1) Objective data obtained from the physical assessment
2) The client’s chief complaint
3) Subjective statements the client makes regarding feelings
4) Conclusions drawn from the data obtained
2) 4
Explanation:
1. Objective data obtained from the physical assessment is an example of the “O” component of SOAP
charting
2. The client’s chief complaint is an example of subjective data, the “S” component of SOAP charting.
, 3. This is another example of subjective data, the “S” component of SOAP charting, because it is
information reported by the client.
4. The “A” component of SOAP charting refers to conclusions drawn from the subjective and objective
data obtained.
Assessment
Knowledge
Objective 7
Page 7
Difficulty -1
3) A nurse is reviewing a client’s medical record. Which is an example of a constant piece of data?
1) The client has B negative blood type.
2) The blood pressure at 0900 was 110/74 mmHg.
3) The sodium level is 145 mmol/L.
4) The client is 64 years of age.
3)1
Explanation:
1. Constant data are things that do not typically change over time such as race, gender, or blood type.
2. Variable data may change within minutes, hours, or days and includes things like blood pressure,
pulse rate, blood counts, and age.
3. Variable data may change within minutes, hours, or days and includes things like blood pressure,
pulse rate, blood counts, and age.
4. Variable data may change within minutes, hours, or days and includes things like blood pressure,
pulse rate, blood counts, and age.
Assessment
Application
Objective 4
Page - 5
Difficulty - 2
4) A nurse is developing a handout for clients in a physician’s office. What content areas would be
included in this handout to emphasize current changes in the healthcare delivery system?
1) Symptom management, environmental control
2) Management of outbreaks of disease, eradicating the use of toxins
3) Illness care, pain management, prevention of complications
4) Wellness, health maintenance, health promotion, prevention of disease
4) 4
Explanation:
1. Historically the Canadian healthcare system focused on illness and symptom control but this has
changed to include a broader focus with an emphasis on wellness, prevention of disease, health
maintenance, and health promotion.
2. Management of outbreaks of disease is a function of governmental organizations and health care
providers in the community, but is not a focus of individual care.
3. Illness care, pain management, and prevention of complications are addressed by the health care
delivery system, but are no longer the primary focus of client care. There is now an emphasis on
wellness, health maintenance, and health promotion.
4. The focus of healthcare in the Canada is now on wellness, prevention of disease, health promotion
and health maintenance.
Assessment
Health Promotion and Management
, Knowledge
Objective 1
Page 3
Difficulty -1
5) What is the best method for the nurse to obtain subjective data during a health assessment?
1) Interviewing a primary source
2) Reviewing an indirect source like health records
3) Completing a physical assessment
4) Obtaining information from a family member
5)1
Explanation:
1. During a health assessment interview, subjective data is best gathered directly from the
client, the primary source.
2. Although subjective data can be obtained through secondary or indirect sources such as
the family, caregivers, other members of the health care team, or medical records, it is
best to obtain such information directly from the client. If secondary sources are used, the
nurse must validate subjective data from other sources to ensure the accuracy of the
information.
3. Objective data is obtained during the physical assessment.
4. A family member can report subjective data based on perceptions the client has shared
with them but it is always best to obtain the subjective data directly from the client when
possible.
Health
Knowledge
Objective 4
Page 5
Difficulty - 2
6) A nurse is reviewing a client’s medical records and notes various forms of information. What piece of
information is an example of subjective data?
1) Symptoms described by the client
2) Physical examination results
3) Results of radiographic studies
4) Laboratory analysis reports
6) 1
Explanation:
1. Clients can describe feelings or symptoms that cannot be observed by others. This is an example of
subjective data.
2. Physical examination results are an example of objective data.
3. Results of radiographic studies are an example of objective data.
4. Laboratory analysis reports are an example of objective data.
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