lOMoAR
cPSD|
37208696
TEST BANK - HEALTH AND PHYSICAL
ASSESSMENT IN NURSING, 4TH EDITION
(Fenske/Watkins/Saunders/D'Amico/B
arbarito)
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.
, lOMoAR
cPSD|
37208696
MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and
its use in nursing.
, lOMoAR
cPSD|
37208696
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.
, lOMoAR
cPSD|
37208696
3) 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 healthcare providers to lobby legislators for more funding."
2. "The primary goal of Healthy People 2020 is to assist healthcare 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." Answer: 3
Explanation: 1. Healthcare 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.
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.
3. The Healthy People 2020 initiative is a 10-year strategy intended to promote health,
prevent illness, disability, and premature death.
4. Standards of care in disease management is not a component of the
document. Page Ref: 7
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease
Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple
dimensions of patient centered care; patient/family/community preferences and values;
coordination and integration of care; information, communication, and education;
physical comfort and emotional support; involvement of family and friends; and
transition and continuity. | AACN Essentials Competencies: IX.2. Recognize the
relationship of genetics and genomics to health, prevention, screening, diagnostics,
prognostics, selection of treatment, and monitoring of treatment effectiveness, using a
constructed pedigree from collected family history information as well as standardized
symbols and terminology. | NLN Competencies: Teamwork: Adapt communication to the
team and situation to share information or solicit input and initiate requests for help
when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.6: Describe the concepts of health, wellness, and health
disparities. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based
practice and its use in nursing.
cPSD|
37208696
TEST BANK - HEALTH AND PHYSICAL
ASSESSMENT IN NURSING, 4TH EDITION
(Fenske/Watkins/Saunders/D'Amico/B
arbarito)
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.
, lOMoAR
cPSD|
37208696
MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and
its use in nursing.
, lOMoAR
cPSD|
37208696
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.
, lOMoAR
cPSD|
37208696
3) 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 healthcare providers to lobby legislators for more funding."
2. "The primary goal of Healthy People 2020 is to assist healthcare 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." Answer: 3
Explanation: 1. Healthcare 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.
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.
3. The Healthy People 2020 initiative is a 10-year strategy intended to promote health,
prevent illness, disability, and premature death.
4. Standards of care in disease management is not a component of the
document. Page Ref: 7
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease
Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple
dimensions of patient centered care; patient/family/community preferences and values;
coordination and integration of care; information, communication, and education;
physical comfort and emotional support; involvement of family and friends; and
transition and continuity. | AACN Essentials Competencies: IX.2. Recognize the
relationship of genetics and genomics to health, prevention, screening, diagnostics,
prognostics, selection of treatment, and monitoring of treatment effectiveness, using a
constructed pedigree from collected family history information as well as standardized
symbols and terminology. | NLN Competencies: Teamwork: Adapt communication to the
team and situation to share information or solicit input and initiate requests for help
when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.6: Describe the concepts of health, wellness, and health
disparities. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based
practice and its use in nursing.
