Test Bank for
Health & Physical Assessment
in Nursing
Health & Physical
Assessment in Nursing
Fourth Edition
Cynthia Fenske
Katherine Watkins
Tina Saunders
Donita D’Amico
Colleen Barbarito
,Health & Physical Assessment in
Nursing, 4e
(Fenske/Watkins/Saunders/D'Amico/
Barbarito)
Chapter 1 Health Assessment
1) A client with a self-reported history of type 2 diabetes mellitus and an ulcer wound
on the left foot states to the nurse, "I am healthy, I don't know why I have to be here
to get a check-up." 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?"
Answer: 2
Explanation: 1. More information would be needed before the nurse could attribute the
client's viewpoint as denial or lack of knowledge.
2. During the process of gathering the subjective data from the client, the nurse must be
attuned to what the patient says, along with the signs, symptoms, behaviors, and cues
offered by the patient. This situational awareness and focused data collection will
enable the nurse to create a comprehensive database about the patient.
3. The client's history of type 2 diabetes requires further investigation but the nurse
must first ascertain the client's definition of what healthy means.
4. There is not enough information to determine the client's withholding of information
to the nurse.
Page Ref: 4
Cognitive Level: Analyzing
Client Need & Sub: Physiological Adaptation; Illness Management
Standards: 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:
Environmental health; health promotion/disease prevention (e.g., transmission of
disease, disease patterns, epidemiological principles); chronic disease management;
healthcare systems; transcultural approaches to health; and family dynamics. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.5: Apply the critical thinking process to health assessment in
nursing.
MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and
its use in nursing.
,
, 2) The nurse is preparing to provide teaching to a client at risk for diabetes. During
which time should the nurse recognize is the most effective moment for teaching?
1. During health promotion.
2. When the client is ready to learn.
3. During the discussion of disease prevention.
4. When a knowledge deficit has been identified.
Answer: 2
Explanation: 1. Health promotion is important; however, if the client is not ready to
learn new information, the teaching may be ineffective.
2. A client must be ready to learn new information or the teaching may be ineffective.
3. Disease prevention is important; however, if the client is not ready to learn new
information, the teaching may be ineffective.
4. Once the knowledge deficit is identified, it is important that client is ready to learn or
the teaching may be ineffective.
Page Ref: 2
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease
Prevention
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values,
clinical expertise, and evidence. | AACN Essentials Competencies: IX.7. Provide
appropriate patient teaching that reflects developmental stage, age, culture, spirituality,
patient preferences, and health literacy considerations to foster patient engagement in
their care. | NLN Competencies: Relationship Centered Care: Factors that contribute to
or threaten health; communicate information effectively; and listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1.3: Explain the steps of the nursing process.
MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional
nurse in healthcare.
Health & Physical Assessment
in Nursing
Health & Physical
Assessment in Nursing
Fourth Edition
Cynthia Fenske
Katherine Watkins
Tina Saunders
Donita D’Amico
Colleen Barbarito
,Health & Physical Assessment in
Nursing, 4e
(Fenske/Watkins/Saunders/D'Amico/
Barbarito)
Chapter 1 Health Assessment
1) A client with a self-reported history of type 2 diabetes mellitus and an ulcer wound
on the left foot states to the nurse, "I am healthy, I don't know why I have to be here
to get a check-up." 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?"
Answer: 2
Explanation: 1. More information would be needed before the nurse could attribute the
client's viewpoint as denial or lack of knowledge.
2. During the process of gathering the subjective data from the client, the nurse must be
attuned to what the patient says, along with the signs, symptoms, behaviors, and cues
offered by the patient. This situational awareness and focused data collection will
enable the nurse to create a comprehensive database about the patient.
3. The client's history of type 2 diabetes requires further investigation but the nurse
must first ascertain the client's definition of what healthy means.
4. There is not enough information to determine the client's withholding of information
to the nurse.
Page Ref: 4
Cognitive Level: Analyzing
Client Need & Sub: Physiological Adaptation; Illness Management
Standards: 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:
Environmental health; health promotion/disease prevention (e.g., transmission of
disease, disease patterns, epidemiological principles); chronic disease management;
healthcare systems; transcultural approaches to health; and family dynamics. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.5: Apply the critical thinking process to health assessment in
nursing.
MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and
its use in nursing.
,
, 2) The nurse is preparing to provide teaching to a client at risk for diabetes. During
which time should the nurse recognize is the most effective moment for teaching?
1. During health promotion.
2. When the client is ready to learn.
3. During the discussion of disease prevention.
4. When a knowledge deficit has been identified.
Answer: 2
Explanation: 1. Health promotion is important; however, if the client is not ready to
learn new information, the teaching may be ineffective.
2. A client must be ready to learn new information or the teaching may be ineffective.
3. Disease prevention is important; however, if the client is not ready to learn new
information, the teaching may be ineffective.
4. Once the knowledge deficit is identified, it is important that client is ready to learn or
the teaching may be ineffective.
Page Ref: 2
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease
Prevention
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values,
clinical expertise, and evidence. | AACN Essentials Competencies: IX.7. Provide
appropriate patient teaching that reflects developmental stage, age, culture, spirituality,
patient preferences, and health literacy considerations to foster patient engagement in
their care. | NLN Competencies: Relationship Centered Care: Factors that contribute to
or threaten health; communicate information effectively; and listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1.3: Explain the steps of the nursing process.
MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional
nurse in healthcare.
