Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico – Test Bank

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Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico – Test Bank

 

Sample  Questions

 

D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e

Chapter 7

 

Question 1

Type: MCMA

While interviewing the client during the focused interview, the client begins to cry softly. Which interventions by the nurse are appropriate?

Standard Text: Select all that apply.

  1. The nurse states, “It’s all right, I think we’re done with the interview.”
  2. The nurse places the tissues within arm’s reach of the client.
  3. The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview.
  4. The nurse states, “I don’t like these questions any more than you do, but we need to get on with the interview so you can go home and cry later.”
  5. The nurse states, “I can see you are upset. It’s all right to cry.”

Correct Answer: 2, 3, 5

Rationale 1: It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning.

Rationale 2: When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client.

Rationale 3: It is appropriate for the nurse to remain quiet while the client cries.

Rationale 4: The nurse should not hurry the interview along or not provide time for the client to display emotion.

Rationale 5: It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad.

Global Rationale: When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client. It is appropriate for the nurse to remain quiet while the client cries. It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad. It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning. The nurse should not hurry the interview along or not provide time for the client to display emotion.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

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: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–115

 

Question 2

Type: MCMA

The nurse recently gave birth to a stillborn infant. During the pre-interaction stage, the nurse learns that the client has had five elective abortions performed while she was in high school and college. Which nursing actions are appropriate to help the nurse prepare emotionally for the initial interview with this client?

Standard Text: Select all that apply.

  1. The nurse speaks with one of her nursing peers and sets up a time to role-play the interview.
  2. The nurse writes in her journal regarding her fears about meeting with the client.
  3. The nurse makes an appointment to meet with her counselor prior to the interview.
  4. The nurse should remain very quiet during the interview so that the initial interview will only last for a brief time.
  5. The nurse creates a list of her own goals to accomplish during the interview with this client.

Correct Answer: 1, 2, 3, 5

Rationale 1: The nurse should speak with one of her nursing peers to role-play how the interview may proceed.

Rationale 2: The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client.

Rationale 3: The nurse can make an appointment to speak with her counselor about her feelings prior to the interview.

Rationale 4: The nurse will not be able to elicit an adequate amount of information from the client if she is focusing only on being quiet during the interview.

Rationale 5: The nurse can create a list of goals to accomplish during the interview.

Global Rationale: The nurse should speak with one of her nursing peers to role-play how the interview may proceed. The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client. The nurse can make an appointment to speak with her counselor about her feelings prior to the interview. The nurse can create a list of goals to accomplish during the interview. The nurse will not be able to elicit an adequate amount of information if she is focusing only on being quiet during the interview.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

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: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–115

 

Question 3

Type: MCMA

The student nurse and the experienced nurse are meeting with an elderly Vietnamese client who is unable to speak English. Which actions indicate that the student nurse requires further education?

Standard Text: Select all that apply.

  1. The student nurse looks intently at the translator during the interview.
  2. The student nurse is sitting directly beside the client and both of them are facing the translator.
  3. The student nurse asks one question at a time.
  4. The student nurse has requested that the client bring his daughter to the interview to translate for him.
  5. The student nurse states, “Please tell him to void in this specimen container and to use a clean-catch technique when acquiring the urine.”

Correct Answer: 1, 2, 4, 5

Rationale 1: The student nurse should look at the client during the interview, not at the translator.

Rationale 2: The student nurse should sit across from the client. The translator should sit next to the client.

Rationale 3: The student nurse should ask one question at a time.

Rationale 4: The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation.

Rationale 5: The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well.

Global Rationale: The student nurse should look at the client during the interview, not at the translator. The student nurse should sit across from the client. The translator should sit next to the client. The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation. The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well. The student nurse should ask one question at a time.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families.

AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Explain the potential effects of cultural and lifespan influences on communication between the nurse and the patient.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–115; 117

 

Question 4

Type: MCSA

The nurse is interviewing the client. The nurse states, “Can you tell me exactly how you feel when you are having difficulty catching your breath?” Which communication technique is the nurse specifically using during this client interaction?

  1. Focusing.
  2. Attending.
  3. Paraphrasing.
  4. Summarizing.

Correct Answer: 1

Rationale 1: Focusing is used to help the client zero in on a subject or get in touch with feelings.

Rationale 2: Attending is when the nurse gives the client undivided attention.

Rationale 3: Paraphrasing or clarifying is when the nurse restates the client’s basic message to test whether it was understood.

Rationale 4: Summarizing is when the nurse ties together the various messages that the client has communicated throughout the interview.

Global Rationale: Focusing is used to help the client zero in on a subject or get in touch with feelings. Attending is when the nurse gives the client undivided attention. Paraphrasing or clarifying is when the nurse restates the client’s basic message to test whether it was understood. Summarizing is when the nurse ties together the various messages that the client has communicated throughout the interview.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

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.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Implement effective interviewing and communication techniques throughout each phase of the patient interview.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 114

 

Question 5

Type: MCSA

The nurse is interviewing the client. The nurse says to the client, “It sounds like you don’t like your new job because it’s more stressful than you anticipated.” Which communication technique is the nurse using in this interaction with the client?

  1. Listening.
  2. Attending.
  3. Questioning.
  4. Paraphrasing.

Correct Answer: 4

Rationale 1: Listening is paying undivided attention to what the client says and does.

Rationale 2: Giving full attention to verbal and nonverbal messages is called attending. Body language may be as much as 93% of the message a client sends.

Rationale 3: Questioning is a very direct way of speaking with clients to obtain subjective data for decision-making and planning care. Questioning techniques include closed and open-ended questions.

Rationale 4: Communication skills include checking to make sure that the nurse has understood the client accurately by paraphrasing. Paraphrasing, or clarification, means that the nurse restates the client’s basic message back to the client to ensure that the nurse understood the client’s message correctly.

Global Rationale: Communication skills include checking to make sure that the nurse has understood the client accurately by paraphrasing. Paraphrasing, or clarification, means that the nurse restates the client’s basic message back to the client to ensure that the nurse understood the client’s message correctly. Listening is paying undivided attention to what the client says and does. Giving full attention to verbal and nonverbal messages is called attending. Body language may be as much as 93% of the message a client sends. Questioning is a very direct way of speaking with clients to obtain subjective data for decision-making and planning care. Questioning techniques include closed and open-ended questions.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

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.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Implement effective interviewing and communication techniques throughout each phase of the patient interview.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 114

 

Question 6

Type: MCSA

The nurse is interviewing the client. Which technique should the nurse use to decode the client’s messages?

  1. Listen actively and attentively.
  2. Develop and transmit an idea.
  3. Use words to convey the message.
  4. Use body language to convey the message.

Correct Answer: 1

Rationale 1: Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively.

Rationale 2: Developing and transmitting an idea is how communication takes place.

Rationale 3: Choosing words to convey a message is the definition of encoding.

Rationale 4: Displaying body language to convey a message is the definition of encoding.

Global Rationale: Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively. Developing and transmitting an idea is how communication takes place. Choosing words and symbols to convey a message is the definition of encoding. Displaying body language to convey a message is the definition of encoding.

Cognitive Level: Remembering

Client Need: Psychosocial Integrity

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.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Implement effective interviewing and communication techniques throughout each phase of the patient interview.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–115

 

Question 7

Type: MCSA

A client tells the nurse about two abortions performed during college. The nurse responds, “What did you major in while you were in college?” This response is evidence of which type of barrier to communication?

  1. Changing the subject.
  2. False reassurance.
  3. Cross-examination.
  4. Use of technical terms.

Correct Answer: 1

Rationale 1: This is an example of changing the subject. This nurse is changing the subject, which shows insensitivity to the client’s thoughts and feelings. This happens when the nurse is not at ease with the client’s comments and is unable to deal with the content.

Rationale 2: False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it.

Rationale 3: Cross-examination is when questions are repeatedly directed to a client, causing the client to feel threatened.

Rationale 4: Use of technical terms is when the nurse uses terms that are specific to the medical field.

Global Rationale: This is an example of changing the subject. This nurse is changing the subject, which shows insensitivity to the client’s thoughts and feelings. This happens when the nurse is not at ease with the client’s comments and is unable to deal with the content. False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it. Cross-examination is when questions are repeatedly directed to a client causing the client to feel threatened. Use of technical terms is when the nurse uses terms that are specific to the medical field.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively.

NLN Competencies: Relationship Centered Care: Effective communication.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.2: Analyze barriers to effective nurse-patient communication.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 115–116

 

Question 8

Type: MCSA

The nurse is interviewing a client who is in acute pain. Which action by the nurse is the priority?

  1. Interview the family for the information.
  2. Attempt to reduce the pain and complete the interview later.
  3. Proceed very quickly with the interview.
  4. Document why the interview could not be completed.

Correct Answer: 2

Rationale 1: Although secondary sources (family members, the medical record, and other members of the healthcare team) can be used to gather data, the client provides the primary information and should be the first choice for data assessment when possible.

Rationale 2: The ability to participate in an interview is diminished when the client is experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain, and then gather in-depth information at another time.

Rationale 3: The client will not be able to concentrate and provide as in-depth information as possible if experiencing pain; regardless of how fast or slow the process takes.

Rationale 4: Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data.

Global Rationale: The ability to participate in an interview is diminished when the client is experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain, and then gather in-depth information at another time. Although secondary sources (family members, the medical record, and other members of the healthcare team) can be used to gather data, the client provides the primary information and should be the first choice for data assessment when possible. The client will not be able to concentrate and provide as in-depth information as possible if experiencing pain; regardless of how fast or slow the process takes. Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication

AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively.

NLN Competencies: Relationship Centered Care: Effective communication.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.2: Analyze barriers to effective nurse-patient communication.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 115–116

 

Question 9

Type: MCSA

The nurse is admitting a young client of Cuban descent to the hospital. Which action by the nurse is culturally sensitive to this client?

  1. Allowing all family members to be present during the admission.
  2. Ensuring that the father of the young client is provided with adequate amounts of information regarding the young client’s care.
  3. Requesting that all family members wait in the waiting room.
  4. Ensuring that the mother of the young client is provided with adequate amounts of information regarding the young client’s care.

Correct Answer: 2

Rationale 1: The head of the Cuban household is the male. The client’s father should be recognized as the decision maker in this family.

Rationale 2: The head of the Cuban household is the male. The client’s father will most likely make decisions regarding the young client’s care.

Rationale 3: The head of the Cuban household is the male. The client’s father should be recognized as the decision maker in this family.

Rationale 4: The head of the Cuban household is the male. The father should be included when providing care for the young client. Native American groups look to mothers and grandmothers to make healthcare decisions. In Filipino households the authority in the family is shared, yet the decisions related to health care are made mostly by the women.

Global Rationale: The head of the Cuban household is the male. The father should be provided with appropriate information regarding the young client’s care. The client’s father will most likely make decisions regarding the young client’s care. Native American groups look to mothers and grandmothers to make healthcare decisions. In Filipino households the authority in the family is shared, yet the decisions related to health care are made mostly by the women. Determination of roles and relationships is important when planning health care and assisting the client to make healthcare decisions, and the nurse should be prepared to include recognized decision makers in the planning process.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families.

AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Explain the potential effects of cultural and lifespan influences on communication between the nurse and the patient.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–116

 

Question 10

Type: SEQ

The nurse is preparing to conduct an initial client interview. Rank the nursing statements in the order in which they would most likely occur.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. “We’re almost done; do you have any questions for me?”

Response 2. “May I call you Anne?”

Response 3. “When you said you had been having trouble with your belly, what did you mean?”

Response 4. “So, can you tell me about what’s been going on with your health?”

Correct Answer: 2, 4, 3, 1

Rationale 1: The nurse should then close the interview by allowing the client to ask questions.

Rationale 2: The nurse should first greet the client and ask if it is all right to call the client by her first name.

Rationale 3: The nurse should ask questions to clarify information given by the client during the interview.

Rationale 4: The nurse should initially ask generalized open-ended questions about the client’s health status.

Global Rationale: The nurse should greet the client and ask if it is all right to call the client by her first name. The nurse should initially generalized open-ended questions about the client’s health status. The nurse should ask questions to clarify information given by the client during the interview. The nurse should then close the interview by allowing the client to ask questions.

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.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Implement effective interviewing and communication techniques throughout each phase of the patient interview.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 117–121

 

Question 11

Type: MCSA

While conducting the client’s health history, the nurse makes little eye contact with the client and focuses intently upon the computer while documenting the client’s information. The nurse faces the computer with legs crossed. Which behavior is this nurse exhibiting?

  1. A lack of empathy.
  2. A lack of genuineness.
  3. A lack of concreteness.
  4. A lack of positive regard.

Correct Answer: 2

Rationale 1: Empathy is the capacity to respond to another’s feelings and experiences as if they were your own. To a lesser extent, the nurse is displaying a lack of empathy by not communicating well with the client.

Rationale 2: Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial expressions appropriate to the situation, and open body language. Facing the client, leaning forward during conversation, and sitting with arms and legs uncrossed are examples of open body language.

Rationale 3: Concreteness means speaking to the client in specific terms instead of vague generalities. The nurse isn’t necessarily providing vague information for the client.

Rationale 4: Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse is demonstrating a lack of positive regard.

Global Rationale: Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial expressions appropriate to the situation, and open body language. Facing the client, leaning forward during conversation, and sitting with arms and legs uncrossed are examples of open body language. Empathy is the capacity to respond to another’s feelings and experiences as if they were your own. To a lesser extent, the nurse is displaying a lack of empathy by not communicating well with the client. Concreteness means speaking to the client in specific terms instead of vague generalities. The nurse isn’t necessarily providing vague information for the client. Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse is demonstrating a lack of positive regard.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships

AACN Essentials Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship.

NLN Competencies: Relationship Centered Care: Positions (a) caring; (b) therapeutic relationships with patients, families, and communities; and (c) professional relationships with members of the health care team at the core of nursing practice. It integrates and reflects respect for the dignity and uniqueness of others, valuing, diversity, integrity, humility, mutual trust, self-determination, empathy, civility, the capacity for grace, and empowerment.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.3: Outline the professional characteristics used in establishing a nurse-patient relationship.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 117

 

Question 12

Type: MCSA

The nurse is conducting a health history interview. By making direct eye contact with the client, which interactional skill is the nurse using with this client?

  1. Attending.
  2. Paraphrasing.
  3. Focusing.
  4. Reflecting.

Correct Answer: 1

Rationale 1: By making direct eye contact with the client during the health history interview, the nurse is exhibiting the interactional skill of attending.

Rationale 2: Paraphrasing is restating the patient’s basic message to test whether it was understood.

Rationale 3: Focusing is helping the patient zero in on a subject or get in touch with feelings.

Rationale 4: Reflecting is letting the patient know that the nurse empathizes with the thoughts, feelings, or experiences expressed.

Global Rationale: By making direct eye contact with the client during the health history interview, the nurse is exhibiting the interactional skill of attending. Paraphrasing is restating the patient’s basic message to test whether it was understood. Focusing is helping the patient zero in on a subject or get in touch with feelings. Reflecting is letting the patient know that the nurse empathizes with the thoughts, feelings, or experiences expressed.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

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: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 114

 

Question 13

Type: MCSA

The nurse is conducting a health history for a client newly admitted to the hospital. Which question by the nurse is open-ended?

  1. “Are you in pain?”
  2. “Do you have difficulty sleeping?”
  3. “Are you married?”
  4. “When was your last tetanus shot?”

Correct Answer: 4

Rationale 1: Asking the client if they are in pain is an example of a close-ended question as it can be answered with a “yes,” “no,” or “maybe.”

Rationale 2: Asking the client if they are having trouble sleeping is an example of a close-ended question as it can be answered with a “yes,” “no,” or “maybe.”

Rationale 3: Asking the client if they are married is an example of a close-ended question as it can be answered with a “yes,” “no,” or “maybe.”

Rationale 4: Asking the client when they received their last tetanus shot is an example of an open-ended question because it cannot be answered with a “yes,” “no,” or “maybe.”

Global Rationale: Open-ended questions cannot be answered with a simple “yes,” “no,” or “maybe.” These questions gather specific information on a topic through the process of inquiry.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

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: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 114

 

Question 14

Type: MCSA

While conducting a health history interview, the nurse restates the client’s basic message to test whether it was appropriately understood. Which interactional skill is the nurse using with this technique?

  1. Attending.
  2. Paraphrasing.
  3. Reflecting.
  4. Summarizing.

Correct Answer: 2

Rationale 1: Attending is giving the client undivided attention.

Rationale 2: Paraphrasing/clarification are restating the client’s basic message to test whether it was understood.

Rationale 3: Reflecting is letting the client know that the nurse empathizes with the thoughts, feelings, or experiences expressed.

Rationale 4: Summarizing is tying together the various messages that the client has communicated throughout the interview.

Global Rationale: Paraphrasing/clarification are restating the client’s basic message to test whether it was understood. Attending is giving the client undivided attention. Reflecting is letting the client know that the nurse empathizes with the thoughts, feelings, or experiences expressed. Summarizing is tying together the various messages that the client has communicated throughout the interview.

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

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: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 114

 

Question 15

Type: MCSA

The nurse is conducting a health history interview for a client who is experiencing symptoms of asthma. The nurse asks the client, “When did your symptoms begin?” Which interactional skill is the nurse using by asking this question?

  1. Attending.
  2. Leading.
  3. Focusing.
  4. Questioning.

Correct Answer: 2

Rationale 1: Attending is giving the client undivided attention.

Rationale 2: Leading directions the client in order to obtain specific information or to begin an interaction.

Rationale 3: Focusing is helping the patient zero in on a subject or get in touch with feelings.

Rationale 4: Questioning gathers specific information on a topic through the process of inquiry.

Global Rationale: Leading directions the client in order to obtain specific information or to begin an interaction. Attending is giving the client undivided attention. Focusing is helping the patient zero in on a subject or get in touch with feelings. Questioning gathers specific information on a topic through the process of inquiry.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

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: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 114

 

Question 16

Type: MCSA

What is occurring when the nurse unknowingly hinders the flow of information during the health history process?

  1. Therapeutic interaction.
  2. Non-therapeutic interaction.
  3. False assurance.
  4. Cross-examination.

Correct Answer: 2

Rationale 1: This is not an example of a therapeutic interaction.

Rationale 2: A non-therapeutic interaction occurs when the nurse unknowingly hinders the flow of information during the health history process.

Rationale 3: While giving false assurance is a type of non-therapeutic interaction, this is not an example of this false assurance.

Rationale 4: While cross-examination is a type of non-therapeutic interaction, this is not an example of cross-examination.

Global Rationale: A non-therapeutic interaction occurs when the nurse unknowingly hinders the flow of information during the health history process. This is not an example of a therapeutic interaction, false assurance, or cross-examination.

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively.

NLN Competencies: Relationship Centered Care: Effective communication.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7.2: Analyze barriers to effective nurse-patient communication.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 115–116

 

Question 17

Type: MCSA

An adolescent client is admitted to the emergency department with a possible urinary tract infection. The nurse asks, “When did you notice that urinating was painful?” Which barrier to communication does this exhibit?

  1. Providing false reassurance.
  2. Passing judgment.
  3. Giving unwanted advice.
  4. Using a technical term.

Correct Answer: 4

Rationale 1: This question does not illustrate providing false assurance.

Rationale 2: This question does not illustrate passing judgment.

Rationale 3: This question does not illustrate giving unwanted advice.

Rationale 4: This question represents the use of a technical term, which is a barrier to communication.

Global Rationale: This question represents the use of a technical term, which is a barrier to communication. This question does not represent the other examples of barriers to communication.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively

NLN Competencies: Relationship Centered Care: Effective communication

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.2: Analyze barriers to effective nurse-patient communication.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 115–116

 

Question 18

Type: MCSA

The nurse is providing education to an adult client recently diagnosed with asthma. The client smokes one pack of cigarettes each day. The nurse states, “Now that you have to quit smoking your friends will no longer complain that you smell like cigarettes.” Which communication barrier does the nurse’s statement represent?

  1. False reassurance.
  2. Cross-examination.
  3. Unwanted advice.
  4. Technical terms.

Correct Answer: 3

Rationale 1: The nurse’s statement does not provide the client with false assurance.

Rationale 2: The nurse’s statement is not an example of cross-examination.

Rationale 3: The nurse’s statement focuses on the social stigma of smoking rather than the physiological benefits of smoking cessation. This is an example of unwanted advice.

Rationale 4: The nurse’s statement is not an example of using technical terms.

Global Rationale: The nurse’s statement focuses on the social stigma of smoking rather than the physiological benefits of smoking cessation. This is an example of unwanted advice. The nurse is not providing false assurance, using cross-examination, or technical terms.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively.

NLN Competencies: Relationship Centered Care: Effective communication.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7.2: Analyze barriers to effective nurse-patient communication.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 115–116

 

Question 19

Type: MCSA

The nurse is providing care to a client who lost a pregnancy in the 14th week due to spontaneous abortion. The client is tearful during the assessment process. The nurse states, “These things always happen for a reason. You can always get pregnant again.” Which barrier to communication does the nurse’s statement represent?

  1. False reassurance.
  2. Change of subject.
  3. Cross-examination.
  4. Unwanted advice.

Correct Answer: 1

Rationale 1: Statements such as, “These things happen for a reason. You can always get pregnant again” are examples of providing false reassurance to the client.

Rationale 2: The nurse’s statement is not an example of changing the subject.

Rationale 3: The nurse’s statement is not an example of cross-examination.

Rationale 4: The nurse’s statement is not an example of unwanted advice.

Global Rationale: Statements such as, “These things happen for a reason. You can always get pregnant again” are examples of providing false reassurance to the client. The nurse’s statement is not an example of changing the subject, cross-examination, or unwanted advice.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively.

NLN Competencies: Relationship Centered Care: Effective communication

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.2: Analyze barriers to effective nurse-patient communication.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 115–116

 

Question 20

Type: MCSA

The nurse is conducting a health history interview for a client being seen in a community clinic. When the nurse exhibits a willingness to help, which client behavior is expected in return?

  1. Cooperation.
  2. Non-compliance.
  3. Attitude.
  4. Anger.

Correct Answer: 1

Rationale 1: By exhibiting a willingness to the help, the client is more likely to be cooperative during the nurse-client interaction.

Rationale 2: Non-compliance is not the expected client behavior in this situation.

Rationale 3: Attitude is not the expected client behavior in this situation.

Rationale 4: Anger is not the expected client behavior in this situation.

Global Rationale: By exhibiting a willingness to the help, the client is more likely to be cooperative during the nurse-client interaction. Non-compliance, attitude, or anger are not the expected client behaviors in this situation.

Cognitive Level: Remembering

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships.

AACN Essentials Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship.

NLN Competencies: Relationship Centered Care: Positions (a) caring; (b) therapeutic relationships with patients, families, and communities; and (c) professional relationships with members of the health care team at the core of nursing practice. It integrates and reflects respect for the dignity and uniqueness of others, valuing, diversity, integrity, humility, mutual trust, self-determination, empathy, civility, the capacity for grace, and empowerment.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7.3: Outline the professional characteristics used in establishing a nurse-patient relationship.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 117

 

Question 21

Type: MCSA

When conducting a client health history, the nurse asks that all calls go to voice mail during the interview process. Which professional characteristic is the nurse exhibiting to establish a nurse-client relationship with this action?

  1. Positive regard.
  2. Empathy.
  3. Genuineness.
  4. Concreteness.

Correct Answer: 3

Rationale 1: This is not an example of positive regard.

Rationale 2: This is not an example of empathy.

Rationale 3: By asking to not be disturbed during the interview process with the client, the nurse is exhibiting genuineness.

Rationale 4: This is not an example of concreteness.

Global Rationale: By asking to not be disturbed during the interview process with the client, the nurse is exhibiting genuineness. This is not an example of positive regard, empathy, or concreteness.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships.

AACN Essentials Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship.

NLN Competencies: Relationship Centered Care: Positions (a) caring; (b) therapeutic relationships with patients, families, and communities; and (c) professional relationships with members of the health care team at the core of nursing practice. It integrates and reflects respect for the dignity and uniqueness of others, valuing, diversity, integrity, humility, mutual trust, self-determination, empathy, civility, the capacity for grace, and empowerment.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.3: Outline the professional characteristics used in establishing a nurse-patient relationship.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 117

 

Question 22

Type: MCSA

While conducting the health history the nurse states, “I need this information to plan dietary changes that will benefit your type 1 diabetes mellitus.” This statement is an example of which professional characteristic in establishing a nurse-client relationship?

  1. Positive regard.
  2. Empathy.
  3. Genuineness.
  4. Concreteness.

Correct Answer: 4

Rationale 1: The statement by the nurse is not an example of positive regard.

Rationale 2: The statement by the nurse is not an example of empathy.

Rationale 3: The statement by the nurse is not an example of genuineness.

Rationale 4: This statement is an example of concreteness. For the nurse, concreteness means speaking to the client in specific terms rather than in vague generalities.

Global Rationale: This statement is an example of concreteness. For the nurse, concreteness means speaking to the client in specific terms rather than in vague generalities. The statement does not reflect positive regard, empathy, or genuineness.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships.

AACN Essentials Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship.

NLN Competencies: Relationship Centered Care: Positions (a) caring; (b) therapeutic relationships with patients, families, and communities; and (c) professional relationships with members of the health care team at the core of nursing practice. It integrates and reflects respect for the dignity and uniqueness of others, valuing, diversity, integrity, humility, mutual trust, self-determination, empathy, civility, the capacity for grace, and empowerment.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.3: Outline the professional characteristics used in establishing a nurse-patient relationship.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 117

 

Question 23

Type: MCSA

The nurse is assisting the client onto the examination table. The nurse states, “take your time” but is looking at her watch and appears annoyed. Which professional characteristic in the nurse-client relationship does this nurse lack?

  1. Positive regard.
  2. Empathy.
  3. Genuineness.
  4. Concreteness.

Correct Answer: 3

Rationale 1: This nurse is not exhibiting a lack of positive regard.

Rationale 2: The nurse is not exhibiting a lack of empathy.

Rationale 3: The nurse who tells a client to “take your time” during the interview, but constantly looks at the clock, gives a mixed or incongruent message and lacks genuineness.

Rationale 4: This nurse is not exhibiting a lack of concreteness.

Global Rationale: The nurse who tells a client to “take your time” during the interview, but constantly looks at the clock, gives a mixed or incongruent message and lacks genuineness. The nurse is not exhibiting a lack of positive regard, empathy, or concreteness in this situation.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships.

AACN Essentials Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship.

NLN Competencies: Relationship Centered Care: Positions (a) caring; (b) therapeutic relationships with patients, families, and communities; and (c) professional relationships with members of the health care team at the core of nursing practice. It integrates and reflects respect for the dignity and uniqueness of others, valuing, diversity, integrity, humility, mutual trust, self-determination, empathy, civility, the capacity for grace, and empowerment.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.3: Outline the professional characteristics used in establishing a nurse-patient relationship.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 117

 

Question 24

Type: MCSA

Which professional characteristic implies that the nurse respects the client’s ability to understand and recognizes the client’s right to know the details of the plan of care?

  1. Positive regard.
  2. Empathy.
  3. Genuineness.
  4. Concreteness.

Correct Answer: 4

Rationale 1: Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude.

Rationale 2: Empathy is “the capacity to respond to another’s feelings and experiences as if they were your own.”

Rationale 3: Genuineness is the ability to present oneself honestly and spontaneously.

Rationale 4: Speaking to the patient in concrete terms implies that the nurse respects the patient’s ability to understand and recognizes the patient’s right to know the details of the plan of care.

Global Rationale: Speaking to the patient in concrete terms implies that the nurse respects the patient’s ability to understand and recognizes the patient’s right to know the details of the plan of care. Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude. Empathy is “the capacity to respond to another’s feelings and experiences as if they were your own.” Genuineness is the ability to present oneself honestly and spontaneously.

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships.

AACN Essentials Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship.

NLN Competencies: Relationship Centered Care: Positions (a) caring; (b) therapeutic relationships with patients, families, and communities; and (c) professional relationships with members of the health care team at the core of nursing practice. It integrates and reflects respect for the dignity and uniqueness of others, valuing, diversity, integrity, humility, mutual trust, self-determination, empathy, civility, the capacity for grace, and empowerment.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.3: Outline the professional characteristics used in establishing a nurse-patient relationship.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 117

 

Question 25

Type: MCSA

The nurse is preparing to conduct a health history for a pediatric client. Which companion can provide legal consent for treatment for this client without written or verbal parental consent?

  1. An adolescent step-sibling of the child.
  2. A grandparent who lives with the child.
  3. An adult natural sibling of the child.
  4. A step-parent to the child.

Correct Answer: 4

Rationale 1: An adolescent step-sibling is not able to provide consent for treatment, even with written or verbal parental consent.

Rationale 2: A grandparent for the pediatric client could provide consent for treatment, but only with parental consent.

Rationale 3: An adult natural sibling of the child would require written or verbal consent from a parent, step-parent, or legal guardian to consent for treatment.

Rationale 4: Step-parents have the legal right to consent to the treatment of a pediatric client without written or verbal parental consent.

Global Rationale: Step-parents have the legal right to consent to the treatment of a pediatric client without written or verbal parental consent. An adolescent step-sibling is not able to provide consent for treatment, even with written or verbal parental consent. A grandparent for the pediatric client could provide consent for treatment, but only with parental consent. An adult natural sibling of the child would require written or verbal consent from a parent, step-parent, or legal guardian to consent for treatment.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families.

AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process:

Learning Outcome: 7.4: Explain the potential effects of cultural and lifespan influences on communication between the nurse and the patient.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 121–123

 

Question 26

Type: MCSA

The nurse is caring for a client who is admitted to the emergency department (ED) with abdominal pain. The client speaks very little English and requires an emergency appendectomy. The nurse has enlisted the hospital interpreter to explain the procedure and help with informed consent. Which action by the nurse is the most appropriate when the interpreter arrives?

  1. Asking the interpreter to translate as closely as possible the same words used by the professional staff.
  2. Including the family in the process and exchange of information to ensure complete understanding.
  3. Addressing the questions to the interpreter, so nothing is missed.
  4. Asking the interpreter to use a familiar dialect to enhance understanding.

Correct Answer: 1

Rationale 1: An interpreter is an individual who mediates spoken or signed communication between people using different languages without adding, omitting, distorting meaning, or editorializing. The objective of the professional interpreter is for the complete transfer of the thought behind the utterance in one language into an utterance in a second language.

Rationale 2: Asking the client’s family, especially a child or spouse, to act as an interpreter should be avoided.

Rationale 3: The questions should be addressed to the client, not the interpreter.

Rationale 4: It is not the interpreter’s responsibility to determine the dialect with which the client is most familiar.

Global Rationale: An interpreter is an individual who mediates spoken or signed communication between people using different languages without adding, omitting, distorting meaning, or editorializing. The objective of the professional interpreter is for the complete transfer of the thought behind the utterance in one language into an utterance in a second language. . Asking the client’s family, especially a child or spouse, to act as an interpreter should be avoided. The questions should be addressed to the client, not the interpreter. It is not the interpreter’s responsibility to determine the dialect with which the client is most familiar.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families.

AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Explain the potential effects of cultural and lifespan influences on communication between the nurse and the patient.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 116–124

 

Question 27

Type: MCMA

When conducting a focused interview for an older adult client, which interventions by the nurse are appropriate?

Standard Text: Select all that apply.

  1. Establishing rapport.
  2. Insisting adult children stay in the room.
  3. Using a paper robe for infection control purposes.
  4. Ensuring background noise is at a minimum.
  5. Addressing the client as “honey.”

Correct Answer: 1, 4

Rationale 1: When conducting a focused interview for an older adult client it is appropriate for the nurse to establish rapport and ensure that background noise is kept to a minimum.

Rationale 2: The nurse should provide privacy for the client during the interview process.

Rationale 3: Older adult clients often feel uncomfortable in paper robes. It is more appropriate to offer this client a cloth robe.

Rationale 4: When conducting a focused interview for an older adult client it is appropriate for the nurse to establish rapport and ensure that background noise is kept to a minimum.

Rationale 5: The nurse should address the client using an appropriate title with their last name. Addressing the older adult client using the term “honey” is disrespectful.

Global Rationale: When conducting a focused interview for an older adult client it is appropriate for the nurse to establish rapport and ensure that background noise is kept to a minimum. The nurse should provide privacy for the client during the interview process. Older adult clients often feel uncomfortable in paper robes. It is more appropriate to offer this client a cloth robe. The nurse should address the client using an appropriate title with their last name. Addressing the older adult client using the term “honey” is disrespectful.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families.

AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.4: Explain the potential effects of cultural and lifespan influences on communication between the nurse and the patient.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: p. 123

 

Question 28

Type: MCSA

Who is the best source for providing information for the disoriented older adult client?

  1. A sibling of the client who does not speak fluent English.
  2. The adult child of the client who is on the phone.
  3. The client’s spouse at the bedside.
  4. The older adult client’s healthcare provider.

Correct Answer: 3

Rationale 1: A sibling to the client who does not speak fluent English is not an appropriate source for client information.

Rationale 2: The adult client who is on the phone is not the most appropriate source of client information in this situation.

Rationale 3: The client’s spouse, who is at the bedside, is the most appropriate source of information for the client who is disoriented.

Rationale 4: While the healthcare provider is an appropriate person to obtain information from, this is not the most appropriate choice when the client’s spouse is at the bedside.

Global Rationale: The most appropriate person for the nurse to obtain the information from is the client’s spouse. The older adult client who is not oriented is unable to provide information to the nurse during the health history. The other options are not the most appropriate choices when the client’s spouse is at the bedside.

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.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Implement effective interviewing and communication techniques throughout each phase of the patient interview.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 117–118

 

Question 29

Type: MCSA

Which is an appropriate secondary source of information when conducting a health history to obtain accurate information?

  1. The client’s spouse.
  2. The client’s healthcare provider.
  3. The client’s medical record.
  4. The client’s adult child.

Correct Answer: 3

Rationale 1: The client’s spouse, healthcare provider, and adult child can all be used as primary sources of information in certain circumstances.

Rationale 2: The client’s spouse, healthcare provider, and adult child can all be used as primary sources of information in certain circumstances.

Rationale 3: The medical record is an appropriate secondary source of information when needing to obtain accurate information during the health history process.

Rationale 4: The client’s spouse, healthcare provider, and adult child can all be used as primary sources of information in certain circumstances.

Global Rationale: The medical record is an appropriate secondary source of information when needing to obtain accurate information during the health history process. The client’s spouse, healthcare provider, and adult child can all be used as primary sources of information in certain circumstances.

Cognitive Level: Understanding

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.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.5: Implement effective interviewing and communication techniques throughout each phase of the patient interview.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 117–118

 

Question 30

Type: MCMA

Which are the reasons for the nurse conducting a focused interview after the initial interview is complete?

Standard Text: Select all that apply.

  1. To clarify data.
  2. To gather missing information.
  3. To validate nursing diagnoses.
  4. To collect data from the medical record.
  5. To review current health concerns.

Correct Answer: 1, 2, 3

Rationale 1: The purpose of the focused interview is to clarify data, to gather missing information, and to validate nursing diagnoses.

Rationale 2: The purpose of the focused interview is to clarify data, to gather missing information, and to validate nursing diagnoses.

Rationale 3: The purpose of the focused interview is to clarify data, to gather missing information, and to validate nursing diagnoses.

Rationale 4: Collecting data from the medical record and reviewing current health concerns occurs during phase I, pre-interaction.

Rationale 5: Collecting data from the medical record and reviewing current health concerns occurs during phase I, pre-interaction.

Global Rationale: The purpose of the focused interview is to clarify data, to gather missing information, and to validate nursing diagnoses. Collecting data from the medical record and reviewing current health concerns occurs during phase I, pre-interaction.

Cognitive Level: Understanding

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.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7.5: Implement effective interviewing and communication techniques throughout each phase of the patient interview.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 118–121

D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e

Chapter 9

 

Question 1

Type: HOTSPOT

The nurse educator is demonstrating the proper technique for assessing a client for fremitus. Which part of the hand will the instructor use to demonstrate proper technique?

A

 

 

D
C
B

 

 

  1. A.
  2. B.
  3. C.
  4. D.

Correct Answer: 3

Rationale 1: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand.

Rationale 2: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand.

Rationale 3: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand.

Rationale 4: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand.

Global Rationale: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 146

 

Question 2

Type: MCSA

The nurse is preparing to assess the sinuses of an adult client using direct percussion. Which technique is the most appropriate for this assessment?

  1. Using the hyperextended middle finger of the nondominant hand.
  2. Using the closed fist of dominant hand.
  3. Using the palm of the nondominant hand.
  4. Using the fingertips of the dominant hand.

Correct Answer: 4

Rationale 1: Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor.

Rationale 2: Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand.

Rationale 3: The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion.

Rationale 4: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess thorax of an infant and also to assess the sinuses of an adult client.

Global Rationale: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess the thorax of an infant and also to assess the sinuses of an adult client. Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 147

 

Question 3

Type: MCSA

During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which action by the nurse is the most appropriate?

  1. Document this as abnormal.
  2. Wet the chest hair before auscultating the chest.
  3. Place the diaphragm on top of the client’s shirt.
  4. Switch from the diaphragm to the bell.

Correct Answer: 2

Rationale 1: The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal.

Rationale 2: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation.

Rationale 3: Auscultating lung sounds over the client’s clothing will increase rather than decrease friction sounds.

Rationale 4: Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference.

Global Rationale: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation. The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. Auscultation of lung sounds over the client’s clothing will increase rather than decrease friction sounds. Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 148–149

 

Question 4

Type: MCSA

The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment?

  1. Downward pressure of 1–2 cm using the finger pads.
  2. Side to side pressure of ½–1 cm using the finger pads.
  3. Downward pressure of 2–4 cm using the palmar surface of the fingers
  4. Light pressure using the base of the fingers (metacarpophalangeal joints).

Correct Answer: 2

Rationale 1: Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen.

Rationale 2: Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node).

Rationale 3: Deep palpation of 2–4 cm (3/4–1½ in.) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward.

Rationale 4: Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus.

Global Rationale: Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Deep palpation of 2–4 cm (3/4–1½ in.) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 145–147

 

Question 5

Type: SEQ

The nurse is preparing to assess a client’s abdomen. Place the sequence for an abdominal assessment is the correct order.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Percussion.

Response 2. Palpation.

Response 3. Auscultation.

Response 4. Inspection.

Correct Answer: 4, 3, 1, 2

Rationale 1: Percussion is the third step taken during an abdominal assessment.

Rationale 2: Palpation is the last step taken during an abdominal assessment.

Rationale 3: Auscultation is the second step taken during an abdominal assessment.

Rationale 4: Inspection is the first step taken during an abdominal assessment.

Global Rationale: The nurse alters the usual order of the four basic techniques of assessment when examining the abdomen. The correct order for abdominal assessment is inspection, auscultation, percussion, and finally palpation. Percussing and palpating before auscultating could alter the natural sounds of the abdomen. Assessment always begins with inspection. In the assessment of the abdomen, inspection is followed by auscultation, then percussion, and finally palpation. Inspection, palpation, percussion, and auscultation is the usual order of assessment except when assessing the abdomen.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 145

 

Question 6

Type: MCSA

The nurse is inspecting a client’s chest and upper extremities. Which would be the appropriate method for the nurse to assess these body areas?

  1. Examine the right arm, the chest, and then the left arm.
  2. Examine the left arm, the chest, and then the right arm.
  3. Examine the left arm, the right arm, and then the chest.
  4. Examine the chest, and then examine the arms at the conclusion of the exam, as the client is re-dressing.

Correct Answer: 3

Rationale 1: The nurse should compare the left and right arms before moving to the chest.

Rationale 2: The nurse should compare the left and right arms before moving to the chest.

Rationale 3: Inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest.

Rationale 4: The nurse should give the client privacy at the conclusion of the physical assessment to re-dress.

Global Rationale: Inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest. The nurse should give the client privacy at the conclusion of the physical assessment to re-dress.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 145

 

Question 7

Type: MCSA

A client has a reddened area on the left forearm. Which assessment technique should the nurse use to assess this area?

  1. Percussion.
  2. Light palpation.
  3. Moderate palpation.
  4. Deep palpation.

Correct Answer: 2

Rationale 1: Percussion is used to determine the size and shape of organs and masses, and whether underlying tissue is solid or filled with air or fluid.

Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.

Rationale 3: Moderate palpation is used to assess most of the other structures of the body.

Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity.

Global Rationale: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Percussion is used to determine the size and shape of organs and masses, and whether underlying tissue is solid or filled with air or fluid. Moderate palpation is used to assess most of the other structures of the body. Deep palpation is used to assess an organ that lies deep within a body cavity.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 146

 

Question 8

Type: MCSA

While auscultating a client’s lungs, the nurse identifies more than one sound. Which action by the nurse is the most appropriate?

  1. Obtain a stethoscope with longer tubing.
  2. Ask another nurse to listen to the lung sounds.
  3. Hold the stethoscope tubing while listening to the lung sounds.
  4. Close the eyes and focus on one sound at a time.

Correct Answer: 4

Rationale 1: Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds.

Rationale 2: Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard.

Rationale 3: Touching the stethoscope tubing can cause additional sounds and should be avoided.

Rationale 4: Closing the eyes and concentrating on each sound may help the nurse focus on the sound.

Global Rationale: Closing the eyes and concentrating on each sound may help the nurse focus on the sound. Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. Touching the stethoscope tubing can cause additional sounds and should be avoided.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 149

 

Question 9

Type: MCSA

The nurse is assessing a client’s right lower extremity and notes an area of redness. Which part of the hand will the nurse use to further assess the client’s skin?

  1. Fingertips.
  2. Metacarpophalgeal joints.
  3. Dorsal surface.
  4. Ulnar surface.

Correct Answer: 3

Rationale 1: The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus.

Rationale 2: The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus.

Rationale 3: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature.

Rationale 4: The ulnar surface of the hand is also used to assess for fremitus.

Global Rationale: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. The ulnar surface of the hand is also used to assess for fremitus.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 146

 

Question 10

Type: MCSA

The nurse is preparing to percuss the lower lobes of a client’s lungs. Which percussion technique is the most appropriate for the nurse to use during this assessment?

  1. Direct percussion.
  2. Blunt percussion.
  3. Indirect percussion.
  4. Any of the percussion techniques.

Correct Answer: 3

Rationale 1: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult.

Rationale 2: Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow.

Rationale 3: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used.

Rationale 4: In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion.

Global Rationale: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used. Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult. Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow. This method is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 147–148

 

Question 11

Type: MCMA

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session?

Standard Text: Select all that apply.

  1. The stethoscope works by blocking out environmental sounds.
  2. Short tubing provides the listener with the most accurate sounds.
  3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds.
  4. Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection.
  5. The binaurals should fit snugly in the ears.

Correct Answer: 1, 2, 5

Rationale 1: The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body.

Rationale 2: Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound.

Rationale 3: The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds.

Rationale 4: The stethoscope should be cleaned after examining a client to prevent the spread of infection.

Rationale 5: The binaurals should fit snugly yet comfortably in the ears.

Global Rationale: The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body. Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound. The binaurals should fit snugly yet comfortably in the ears. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. The stethoscope should be cleaned after examining a client to prevent the spread of infection.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 148; 151

 

Question 12

Type: MCMA

When is it appropriate for the nurse to use an otoscope during a physical assessment?

Standard Text: Select all that apply.

  1. Inspecting the nose.
  2. Funneling light into the ear canal.
  3. Inspecting the internal structures of the eye.
  4. Assessing pulses that are not palpable.
  5. Detecting fungal infections of the skin.

Correct Answer: 1, 2

Rationale 1: The otoscope can be used to inspect the nose, by inserting a wide speculum into the client’s naris.

Rationale 2: The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself.

Rationale 3: The ophthalmoscope is used to inspect the internal structure of the eye.

Rationale 4: The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate.

Rationale 5: A Wood’s lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection.

Global Rationale: The otoscope can be used to inspect the nose, by inserting a wide speculum into the client’s naris. The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself. The ophthalmoscope is used to inspect the internal structure of the eye. The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate. A Wood’s lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 152–153

 

Question 13

Type: MCSA

The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which color is visualized through the red-free filter of the ophthalmoscope?

  1. Green.
  2. Black.
  3. Red.
  4. Yellow.

Correct Answer: 2

Rationale 1: The color green is not an expected finding of fundoscopic examination of the eye.

Rationale 2: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black.

Rationale 3: The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding.

Rationale 4: Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope.

Global Rationale: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black. The color green is not an expected finding of fundoscopic examination of the eye. The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding. Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 152

 

Question 14

Type: HOTSPOT

B

The nurse educator is teaching a group of nursing students the correct assessment of heart murmurs. Which part of the stethoscope will the educator press against the client’s chest during this assessment?

A

 

 

D
C

 

 

  1. A.
  2. B.
  3. C.
  4. D.

Correct Answer: 2

Rationale 1: The diaphragm of the stethoscope is used to assess normal heart sounds.

Rationale 2: The bell of the stethoscope is used to assess murmurs.

Rationale 3: The earpieces fit into both ears to allow the nurse to hear sounds when auscultating. The earpieces are not placed against the client’s chest during auscultation.

Rationale 4: The tubing length can distort sound; however, this is not placed against the client’s chest during auscultation.

Global Rationale: The bell of the stethoscope is used to assess murmurs. The diaphragm of the stethoscope is used to assess normal heart sounds. The earpieces fit into both ears to allow the nurse to hear sounds when auscultating. The earpieces are not placed against the client’s chest during auscultation. The tubing length can distort sound; however, this is not placed against the client’s chest during auscultation.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 151

 

Question 15

Type: MCSA

The nurse is planning to perform a physical assessment on an adult client. Before beginning this phase of the client’s health assessment, which action by the nurse is the most appropriate?

  1. Provide a gown for the client to change into.
  2. Explain to the client what will happen during the examination.
  3. Obtain a written consent.
  4. Wash hands in the presence of the client.

Correct Answer: 2

Rationale 1: The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing.

Rationale 2: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client’s anxiety and enlists the client’s cooperation with the assessment.

Rationale 3: Obtaining a written consent is not necessary, unless an invasive procedure will be performed.

Rationale 4: Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given and again at the completion of the physical assessment.

Global Rationale: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client’s anxiety and enlists the client’s cooperation with the assessment. The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing. Obtaining a written consent is not necessary, unless an invasive procedure will be performed. Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 154

 

Question 16

Type: MCSA

The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. Which technique is appropriate for the nurse to use when assessing this client’s abdomen?

  1. Palpating known painful areas first.
  2. Touching each area lightly before applying deeper palpation.
  3. Performing the exam as quickly as possible.
  4. Refraining from conversation during the assessment.

Correct Answer: 2

Rationale 1: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense.

Rationale 2: Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction.

Rationale 3: Rushing through the exam will not help with the client’s anxiety.

Rationale 4: The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the client’s health.

Global Rationale: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense. Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction. The nurse should proceed slowly, using smooth, deliberate movements during the exam. The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the client’s health.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 145–147

 

Question 17

Type: MCSA

The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority?

  1. Give the client a short break and then resume the assessment.
  2. Document what was done and what was refused.
  3. Summon another nurse to the room to serve as a witness.
  4. Enlist the assistance of the client’s family to encourage the rest of the assessment.

Correct Answer: 2

Rationale 1: The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion.

Rationale 2: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused.

Rationale 3: It is not necessary for another nurse to witness a client’s refusal of care. The nurse should document what was done and what the client refused.

Rationale 4: Allowing a family member to be present during the assessment may be helpful, but the client’s wishes (refusal) must be respected.

Global Rationale: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion. It is not necessary for another nurse to witness a client’s refusal of care. The nurse should document what was done and what the client refused. Allowing a family member to be present during the assessment may be helpful, but the client’s wishes (refusal) must be respected.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 154

 

Question 18

Type: MCMA

The nurse is preparing to perform a complete health assessment on a client. Which actions by the nurse are appropriate just prior to the examination?

Standard Text: Select all that apply.

  1. Putting on nonsterile gloves.
  2. Providing an opportunity for the client to void.
  3. Washing hands in the presence of the client.
  4. Turning on soft music to relax the client.
  5. Ensuring adequate light in the room.

Correct Answer: 2, 3, 5

Rationale 1: Gloves are needed only if the nurse may come into contact with the client’s blood or body fluids, such as during the assessment of the genitalia or anus.

Rationale 2: The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs.

Rationale 3: The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client’s safety and also protects the nurse.

Rationale 4: The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics.

Rationale 5: The room should be brightly lit to facilitate good visibility.

Global Rationale: The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client’s safety and also protects the nurse. Gloves are needed only if the nurse may come into contact with the client’s blood or body fluids, such as during the assessment of the genitalia or anus. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics. The room should be brightly lit to facilitate good visibility.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 153–154

 

Question 19

Type: MCSA

The nurse is assessing a client’s abdomen. Which sound is expected when percussion is used during the assessment?

  1. Loud, low-pitched.
  2. Soft, high-pitched.
  3. Drum-like.
  4. Abnormally loud.

Correct Answer: 3

Rationale 1: Resonance is a loud, low-pitched tone of normal findings over the lungs.

Rationale 2: Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver.

Rationale 3: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines.

Rationale 4: Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs.

Global Rationale: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Resonance is a loud, low-pitched tone of normal findings over the lungs. Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 148

 

Question 20

Type: MCSA

A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more detailed neurological assessment of this client?

  1. Asymmetry of the client’s smile.
  2. Grimacing with movement.
  3. Talking in a loud voice.
  4. Inability to follow directions.

Correct Answer: 1

Rationale 1: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves.

Rationale 2: Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem.

Rationale 3: Talking in a loud voice may cue the nurse that the client has hearing loss.

Rationale 4: The client’s inability to follow directions may also be the result of a hearing loss.

Global Rationale: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves. Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem. Talking in a loud voice may cue the nurse that the client has hearing loss. The client’s inability to follow directions may also be the result of a hearing loss.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 153–155

 

Question 21

Type: MCSA

The nurse is performing an abdominal assessment and has just completed auscultation. Which technique would the nurse correctly choose to use next in this assessment?

  1. Percussion.
  2. Palpation.
  3. Transillumination.
  4. Auscultation.

Correct Answer: 1

Rationale 1: After auscultating the client’s abdomen, the nurse would begin percussion.

Rationale 2: Palpation is the last step of the abdominal assessment.

Rationale 3: Transillumination of the abdomen is not part of the abdominal assessment.

Rationale 4: Auscultation is the second step of the abdominal assessment.

Global Rationale: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Percussion and palpation could alter the natural sounds of the abdomen; therefore, it is important to auscultate before performing palpation and percussion.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 145

 

Question 22

Type: MCSA

The nurse is using a Doppler ultrasonic stethoscope to assess a client’s pulse in the lower extremity and is unable to locate the pulse. Which action by the nurse is appropriate in this situation?

  1. Checking the pressure applied to the probe.
  2. Adding more gel to the end of the probe.
  3. Informing the healthcare provider immediately.
  4. Sending the equipment for repair.

Correct Answer: 1

Rationale 1: Heavy pressure to the probe should be avoided because it may impede blood flow—the probe should be placed gently against the client’s skin, over the artery to be auscultated.

Rationale 2: A small amount of gel is applied to the end of the Doppler probe to eliminate interference.

Rationale 3: Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly.

Rationale 4: Sending the equipment for repair is premature at this time.

Global Rationale: Heavy pressure to the probe should be avoided because it may impede blood flow—the probe should be placed gently against the client’s skin, over the artery to be auscultated. A small amount of gel is applied to the end of the Doppler probe to eliminate interference. Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly. Sending the equipment for repair is premature at this time.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 151–152

 

Question 23

Type: MCSA

A client has a visible pulsation in the middle of his abdomen. Which assessment technique is appropriate for the nurse to use to assess this pulsation?

  1. Percussion.
  2. Light palpation.
  3. Moderate palpation.
  4. Deep palpation.

Correct Answer: 3

Rationale 1: Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid.

Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.

Rationale 3: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present.

Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity.

Global Rationale: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Deep palpation is used to assess an organ that lies deep within a body cavity.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 146

 

Question 24

Type: MCSA

The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which action by the nurse is appropriate when palpating this client’s abdomen?

  1. Assessing the painful area first using moderate palpation.
  2. Assessing the painful area last using deep palpation.
  3. Assessing the painful area last using light palpation.
  4. Assessing the painful area first using deep palpation.

Correct Answer: 2

Rationale 1: Painful areas are not palpated first.

Rationale 2: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation.

Rationale 3: Light palpation is used to evaluate surface characteristics, not the structures of the abdomen.

Rationale 4: While deep palpation is the appropriate technique, the painful area is examined last.

Global Rationale: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation. Painful areas are not palpated first. Light palpation is used to evaluate surface characteristics, not the structures of the abdomen. While deep palpation is the appropriate technique, the painful area is examined last.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 145–147

 

Question 25

Type: MCSA

While percussing a client’s lung area the nurse notes a resonance. What does the tone indicate?

  1. The nurse is percussing over a bone.
  2. A normal finding.
  3. The lungs are solidified.
  4. Air is trapped in the lungs.

Correct Answer: 2

Rationale 1: Flat tones are high-pitched, soft tones of short duration and are the result of percussion over solid tissue such as muscle or bone.

Rationale 2: Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance.

Rationale 3: Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration.

Rationale 4: Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance.

Global Rationale: Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance. Flat tones are high-pitched, soft tones of short duration are the result of percussion over solid tissue such as muscle or bone. Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration. Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 148

 

Question 26

Type: MCSA

The nurse is unable to palpate a client’s pedal pulses. Which item will the nurse use to assess this client’s pedal pulses?

  1. Stethoscope.
  2. Doppler.
  3. Transilluminator.
  4. Goniometer.

Correct Answer: 2

Rationale 1: A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds.

Rationale 2: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses.

Rationale 3: A transilluminator detects blood, fluid, or masses in body cavities.

Rationale 4: A Goniometer is used to measure the degree of joint flexion and extension.

Global Rationale: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses. A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds. A transilluminator detects blood, fluid, or masses in body cavities. A goniometer is used to measure the degree of joint flexion and extension.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 151–152

 

Question 27

Type: MCSA

While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. Which nursing action is most appropriate?

  1. Informing the client of “the abnormality.”
  2. Stopping the assessment and referring the client to the healthcare provider immediately.
  3. Bring in another examiner to assess the finding.
  4. Documenting the finding and reassessing at the client’s next visit.

Correct Answer: 3

Rationale 1: Informing the client of “the abnormality” may cause the client undue anxiety, as the finding may be a normal variant.

Rationale 2: When the nurse identifies an unfamiliar finding, it is appropriate complete the assessment before referral to a healthcare provider.

Rationale 3: The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse’s unfamiliar finding.

Rationale 4: The finding should be investigated at this visit, first by asking another examiner to assess the concern.

Global Rationale: The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse’s unfamiliar finding. The finding should be investigated at this visit, first by asking another examiner to assess the concern. When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding. Informing the client of “the abnormality” may cause the client undue anxiety, as the finding may be a normal variant.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 153–155

 

Question 28

Type: MCSA

The nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination?

  1. An adult client with flu symptoms.
  2. A preschool-age client in for a well check-up.
  3. An adolescent client who complains of fatigue.
  4. An older adult client with chronic lung disease.

Correct Answer: 4

Rationale 1: A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease.

Rationale 2: Assessment approaches and techniques may vary for children, but a 3-year-old is not considered at the same risk potential as a client with a chronic respiratory illness.

Rationale 3: Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general, the position changes required during the complete health assessment should not be taxing on a teen.

Rationale 4: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion.

Global Rationale: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease. Assessment approaches and techniques may vary for children, but a 3-year-old is not considered at the same risk potential as a client with a chronic respiratory illness. Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general the position changes required during the complete health assessment should not be taxing on a teen.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Apply critical thinking when using the four basic techniques of physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 154

 

Question 29

Type: MCMA

The nurse is preparing to assess an adult client who presents to the emergency department (ED) after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which should the nurse incorporate into the physical assessment of this client?

Standard Text: Select all that apply.

  1. Washing hands in the presence of the client.
  2. Putting on nonsterile gloves to examine the client.
  3. Ensuring that the client has an empty bladder before beginning the physical assessment.
  4. Instructing the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.
  5. Assessing only the left lower extremity since this is the injured body part.

Correct Answer: 1, 2

Rationale 1: The nurse should always perform handwashing prior to physical contact with a client.

Rationale 2: Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens.

Rationale 3: When the client’s abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation.

Rationale 4: The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a client’s anxiety.

Rationale 5: The nurse should always do a comparison of both sides of the body.

Global Rationale: The nurse should always perform handwashing prior to physical contact with a client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens. When the client’s abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation. The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a client’s anxiety. The nurse should always do a comparison of both sides of the body.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality.

AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan.

NLN Competencies: Quality and Safety: Factors that contribute to a system-wide safety culture; The importance of reporting hazards and adverse events; The “just culture” approach to system improvement.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.5: Apply the principles of Standard Precautions in practice.

MNL Learning Outcome: 1.1.1. Identify factors that affect safety across the life span.

Page Number: p. 155

 

Question 30

Type: MCMA

The school nurse provides care for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which actions by the school nurse are appropriate when caring for this child?

Standard Text: Select all that apply.

  1. Putting on nonsterile gloves prior to assessing the child’s injuries.
  2. Disposing of blood-soaked gauze in the office trash bin.
  3. Performing handwashing before touching the child.
  4. Asking the child permission to assess the injuries.
  5. Wearing a mask while washing the child’s abrasions.

Correct Answer: 1, 3, 4

Rationale 1: The use of nonsterile gloves protects the student nurse from direct contact with the child’s blood.

Rationale 2: The school nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin.

Rationale 3: Handwashing should be performed before and after client care.

Rationale 4: Asking permission to assess the child’s injuries gains the child’s attention and cooperation.

Rationale 5: Wearing a mask is not necessary when washing the child’s abrasions.

Global Rationale: The student nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin. The use of nonsterile gloves protects the student nurse from direct contact with the child’s blood. Handwashing should be performed before and after client care. Asking permission to assess the child’s injuries gains the child’s attention and cooperation. Wearing a mask is not necessary when washing the child’s abrasions.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality.

AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan.

NLN Competencies: Quality and Safety: Factors that contribute to a system-wide safety culture; The importance of reporting hazards and adverse events; The “just culture” approach to system improvement.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.5: Apply the principles of Standard Precautions in practice.

MNL Learning Outcome: 1.1.1. Identify factors that affect safety across the life span.

Page Number: p. 155

D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e
Chapter 13

Question 1

Type: HOTSPOT

The nurse preparing to perform a skin assessment while a student nurse observes. The student nurse asks, “Where exactly is the stratum basale located?” Which location will the nurse use to correctly identify this for the student nurse?

B

 

 

 

 

D
C

 

  1. A.
  2. B.
  3. C.
  4. D.

Correct Answer: 1

Rationale 1: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.

Rationale 2: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.

Rationale 3: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.

Rationale 4: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.

Global Rationale: The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The stratum basale is denoted with letter A.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.1: Identify the anatomy and physiology of the skin, hair, and nails.

MNL Learning Outcome: 6.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 212

 

Question 2

Type: HOTSPOT

The nurse is assessing the client’s nail. When assessing the lunula, which location does the nurse use?

 

 

D
C
B
A

 

  1. A.
  2. B.
  3. C.
  4. D.

Correct Answer: 4

Rationale 1: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.

Rationale 2: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.

Rationale 3: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.

Rationale 4: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.

Global Rationale: The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Identify the anatomy and physiology of the skin, hair, and nails.

MNL Learning Outcome: 6.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 213

 

Question 3

Type: MCMA

The nurse is conducting a focused interview on the client’s integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders. Which question by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview?

Standard Text: Select all that apply.

  1. “How much time do you spend outdoors?”
  2. “How do you care for your skin?”
  3. “Do you have any tattoos or body piercings?”
  4. “Have you noticed any drainage from your skin?”
  5. “Do you take any medications on a regular basis?”

Correct Answer: 1, 2, 3, 5

Rationale 1: The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma.

Rationale 2: The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder.

Rationale 3: Tattoos and body piercings can increase the client’s risk for developing an integumentary disorder.

Rationale 4: When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors.

Rationale 5: Certain medications, if taken on a regular basis, can increase the client’s risk for developing skin disorders.

Global Rationale: The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma. The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder. Tattoos and body piercings can increase the client’s risk for developing an integumentary disorder. Certain medications, if taken on a regular basis, can increase the client’s risk for developing skin disorders. When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.

MNL Learning Outcome: 6.1.2. Plan questions to consider when the nurse performs a focused interview during physical assessment.

Page Number: pp. 228–231

 

Question 4

Type: MCSA

The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which question would be most important for the nurse to include in the interview?

  1. “Do you use any skin creams?”
  2. “Do you try to avoid exposure to the sun?”
  3. “Have you lost any hair during your pregnancy?”
  4. “Have you had any nail changes?”

Correct Answer: 1

Rationale 1: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain.

Rationale 2: Client should avoid sun exposure to prevent skin damage, but it is most important to assess the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.

Rationale 3: Losing hair during pregnancy is not necessarily as important to assess as the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.

Rationale 4: Nail changes can be assessed, but it is most important to assess the client’s use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.

Global Rationale: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.

MNL Learning Outcome: 6.1.2. Plan questions to consider when the nurse performs a focused interview during physical assessment.

Page Number: pp. 214–215

 

Question 5

Type: MCSA

The nurse is preparing to assess the client’s skin, hair, and nails. Which technique will the nurse use initially during this assessment?

  1. Percussion.
  2. Palpation.
  3. Auscultation.
  4. Inspection.

Correct Answer: 4

Rationale 1: There is no need to use percussion to assess the client’s skin, hair, and nails.

Rationale 2: The nurse inspects then palpates during the assessment of the client’s skin, hair, and nails.

Rationale 3: There is no need to use auscultation to assess the client’s skin, hair, and nails.

Rationale 4: Inspection is the nurse’s first step when assessing the client’s skin, hair, and nails.

Global Rationale: Physical assessment of the skin, hair, and nails is conducted by inspection and then with palpation. There is no need to use percussion or auscultation to assess the client’s skin, hair, and nails.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.3: Outline the techniques used for assessment of skin, hair, and nails.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: pp. 231–233

 

Question 6

Type: MCMA

The client is visiting the healthcare provider’s office for a head-to-toe assessment. During the nurse’s assessment of the client’s skin, the nurse notes that the client is pale. Which assessment data may be related to the client’s color?

Standard Text: Select all that apply.

  1. Client’s blood pressure is 96/62.
  2. The client states, “I just smoked a cigarette before I came in the office.”
  3. The client’s oxygen saturation level is 86% on room air.
  4. The client states, “I have been diagnosed with osteoporosis.”
  5. The client states, “It is snowing again outside with a wind chill factor of –11 degrees Fahrenheit.”

Correct Answer: 1, 2, 3, 5

Rationale 1: Pallor may be seen in the client with hypotension.

Rationale 2: It can be produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes.

Rationale 3: The client with a decreased oxygen saturation level may exhibit pallor.

Rationale 4: Pallor is not normally associated with osteoporosis.

Rationale 5: A cold environment can produce vasoconstriction and pallor.

Global Rationale: Pallor may be seen in the client with hypotension. It can be produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes. The client with a decreased oxygen saturation level may exhibit pallor. A cold environment can produce vasoconstriction and pallor. It is not normally associated with osteoporosis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 217

 

Question 7

Type: MCSA

The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. Which term is most appropriate for the nurse to use to describe this condition when documenting in the medical record?

  1. Uremia.
  2. Cyanosis.
  3. Jaundice.
  4. Carotenemia.

Correct Answer: 3

Rationale 1: Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes.

Rationale 2: Cyanotic skin is bluish in color.

Rationale 3: The nurse’s findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet.

Rationale 4: Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes.

Global Rationale: The nurse’s findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet. Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes. Cyanotic skin is bluish in color. Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 218

 

Question 8

Type: MCSA

The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. Which term is the most appropriate for the nurse to use when documenting this finding in the medical record?

  1. Vesicle.
  2. Macule.
  3. Papule.
  4. Tumor.

Correct Answer: 1

Rationale 1: The area described is a vesicle and may be caused by herpetic lesions, poison ivy, or small burn blisters.

Rationale 2: A macule is a flat, nonpalpable change in skin color.

Rationale 3: A papule is an elevated, solid, palpable mass.

Rationale 4: Tumors are elevated but solid, hard, or soft palpable, and extend deeper into the dermis.

Global Rationale: The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters. A macule is a flat, nonpalpable change in skin color. A papule is an elevated, solid, palpable mass. Tumors are elevated but solid, hard, or soft palpable, and extend deeper into the dermis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 242

 

Question 9

Type: MCSA

The nurse is caring for a client who has smoked for many years and documents that “clubbing is present.” Which technique is the best way for the nurse to determine the presence of clubbing?

  1. Place two thumbs touching side-by-side.
  2. Place two of the same fingers from each hand together.
  3. Place two index fingers together tip-to-tip.
  4. Place the hands out straight with the palm sides down.

Correct Answer: 2

Rationale 1: Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing.

Rationale 2: To assess for clubbing the nurse can use the Schamroth technique, in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing, a diamond is not formed and the distance increases at the fingertip.

Rationale 3: Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing.

Rationale 4: Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing.

Global Rationale: To assess for clubbing the nurse can use the Schamroth technique, in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing, a diamond is not formed and the distance increases at the fingertip. Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing. Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing. Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 240

 

Question 10

Type: MCSA

The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, “Why did this happen to me?” Which statement is the nurse’s best response?

  1. “Your diet is not nutritionally balanced.”
  2. “You may have some hormone imbalances.”
  3. “Usually, there is not a known cause for this condition.”
  4. “You need to take vitamins.”

Correct Answer: 2

Rationale 1: Hirsutism is not typically linked to nutrition.

Rationale 2: Hirsutism is the occurrence of excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction, but may be idiopathic in nature.

Rationale 3: Hirsutism is typically due to endocrine or metabolic dysfunction.

Rationale 4: Clients with hirsutism do not need more vitamins, since hirsutism is often the result of endocrine or metabolic dysfunction.

Global Rationale: Hirsutism is the occurrence of excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction, but may be idiopathic in nature. Hirsutism is not typically linked to nutrition. Hirsutism is typically due to endocrine or metabolic dysfunction. Clients with hirsutism do not need more vitamins, since hirsutism is often the result of endocrine or metabolic dysfunction.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 255

 

Question 11

Type: MCSA

The nurse is inspecting the fingernails of a client who is diagnosed with polycythemia. Which assessment data would be expected for this client?

  1. Dark red nails.
  2. Horizontal white bands.
  3. Pale nail beds.
  4. Spoon-shaped nails.

Correct Answer: 1

Rationale 1: The client with polycythemia has nails that appear dark red due to a pathological increase in red blood cells.

Rationale 2: Horizontal white bands in the nails are seen with the client who has been diagnosed with chronic hepatitis.

Rationale 3: Pale nail beds are associated with anemia or peripheral circulatory disorders.

Rationale 4: Spoon-shaped nails may be related to iron deficiency.

Global Rationale: The client with polycythemia has nails that appear dark red due to a pathological increase in red blood cells. Horizontal white bands in the nails are seen with the client who has been diagnosed with chronic hepatitis. Pale nail beds are associated with anemia or peripheral circulatory disorders. Spoon-shaped nails may be related to iron deficiency.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 217

 

Question 12

Type: MCSA

The nurse is assessing the skin of an adolescent client and notes the presence of a musky odor. The client states that this is embarrassing for him and that he showers daily. Which action should the nurse take in this situation?

  1. Reassure the teen that this is normal.
  2. Notify the client’s healthcare provider.
  3. Obtain a dietary referral.
  4. Educate the client regarding the importance of increased water intake.

Correct Answer: 1

Rationale 1: The apocrine glands are dormant until the onset of puberty, when they become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in auxiliary and anogenital areas, and when mixed with bacteria on skin surface produces a musky odor. This is a normal part of normal growth and development.

Rationale 2: The teenage client’s healthcare provider does not need to be notified because this odor is associated with normal growth and development.

Rationale 3: The nurse does not need to obtain a dietary referral because this odor is associated with normal growth and development.

Rationale 4: Increasing fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth and development.

Global Rationale: The apocrine glands are dormant until the onset of puberty, when they become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in auxiliary and anogenital areas, and when mixed with bacteria on skin surface produces a musky odor. This is a normal part of normal growth and development. The teenage client’s healthcare provider does not need to be notified because this odor is associated with normal growth and development. The nurse does not need to obtain a dietary referral because this odor is associated with normal growth and development. Increasing fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth and development.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 229

 

Question 13

Type: MCSA

The nurse is caring for a client complaining of a painful, hot area located on the client’s leg. Erythema and edema are present in the localized area. Which action should the nurse perform next?

  1. Palpate the area.
  2. Place a heating pad on the area.
  3. Notify the healthcare provider.
  4. Place client on bed rest.

Correct Answer: 3

Rationale 1: The nurse would not palpate the area. Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers.

Rationale 2: The nurse would not apply a heating pad to this site. Disturbance may spread the infection into skin layers.

Rationale 3: Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers. The healthcare provider should be notified.

Rationale 4: The nurse would not necessarily place the client on bed rest. The healthcare provider should be notified.

Global Rationale: Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers. The healthcare provider should be notified. The nurse would not palpate the area. The nurse would not apply a heating pad to this site. The nurse would not necessarily place the client on bed rest.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 235

 

Question 14

Type: MCSA

The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeters in size. Which term will the nurse use when documenting this assessment data?

  1. Vesicle.
  2. Bulla.
  3. Papule.
  4. Tumor.

Correct Answer: 2

Rationale 1: Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders.

Rationale 2: The area described is a bulla and may be caused by contact dermatitis, friction blisters, or large burn blisters.

Rationale 3: A papule is an elevated, solid palpable mass with a circumscribed border. Papules are smaller than 0.5 centimeters.

Rationale 4: Tumors are elevated, solid, hard, or soft palpable and extend deeper into the dermis.

Global Rationale: The area described is a bulla and may be caused by contact dermatitis, friction blisters, or large burn blisters. Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders. A papule is an elevated, solid, palpable mass with a circumscribed border, usually smaller than 0.5 centimeters. Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 243

 

Question 15

Type: MCSA

The adult client is being assessed at an outpatient clinic and states, “I have sores in my mouth and on my lips.” The nurse notes the presence of crusted lesions on the lips and inside the client’s mouth along the cheek. The client states that the lesions do not itch. Based on this assessment data, which condition is this client likely experiencing?

  1. Chickenpox.
  2. Contact dermatitis.
  3. Herpes simplex.
  4. Psoriasis.

Correct Answer: 3

Rationale 1: Chickenpox is a mild infectious disease caused by the herpes zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk, and progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules, then crusts. The condition may cause intense itching. It occurs mostly in children.

Rationale 2: Contact dermatitis is inflammation of the skin due to an allergy to a substance that comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help identify the allergen. It may progress from redness to hives, vesicles, or scales, and is usually accompanied by intense itching.

Rationale 3: The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions.

Rationale 4: Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp, elbows and knees, lower back, and perianal area.

Global Rationale: The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions. Chickenpox is an infectious disease caused by the herpes zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk, and progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules, then crusts. The condition may cause intense itching. It occurs mostly in children. Contact dermatitis is inflammation of the skin due to an allergy to a substance that comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help identify the allergen. It may progress from redness to hives, vesicles, or scales, and is usually accompanied by intense itching. Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp, elbows and knees, lower back, and perianal area.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 250

 

Question 16

Type: MCSA

The nurse is assessing a client’s skin and notes a very light color on the skin, nails, and the client’s mucous membranes. Which descriptions would the nurse use when documenting this finding?

  1. Cyanosis.
  2. Pallor.
  3. Erythema.
  4. Jaundice.

Correct Answer: 2

Rationale 1: Cyanotic skin is bluish in color.

Rationale 2: Pallor is pale skin. It may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia.

Rationale 3: Erythema indicates that the skin is reddened.

Rationale 4: Jaundice is used to describe yellowish skin.

Global Rationale: Pallor, or paleness of the skin, may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia. Cyanotic skin is blue in color; erythema is redness of the skin; and jaundiced skin has yellow undertones.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 217

 

Question 17

Type: MCSA

The nurse is assessing a client in an outpatient clinical and notes the notes the presence of several abdominal lesions that appear in distinct clusters. When documenting this finding, which term will the nurse use?

  1. Grouped.
  2. Annular.
  3. Discrete.
  4. Confluent.

Correct Answer: 1

Rationale 1: The lesions described are grouped lesions because they appear in clusters.

Rationale 2: Annular lesions are lesions with a circular shape.

Rationale 3: Discrete lesions are lesions that are separate and distinct.

Rationale 4: Confluent lesions run together.

Global Rationale: The lesions described are grouped lesions because they appear in clusters. Annular lesions are lesions with a circular shape. Discrete lesions are separate. Confluent lesions run together.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 249

 

Question 18

Type: MCMA

The nurse completes a skin assessment for a client and is preparing to document the appearance of herpetic lesions found over a client’s nose and mouth region. Which terms can the nurse use when documenting the skin assessment for this client in the medical record?

Standard Text: Select all that apply.

  1. Vesicular.
  2. Pustular.
  3. Pruritic.
  4. Ulcerated.
  5. Crusty.

Correct Answer: 1, 2, 5

Rationale 1: Herpes simplex lesions may be described as vesicular.

Rationale 2: Herpes simplex lesions may be described as pustular.

Rationale 3: Herpes simplex lesions are not associated with pruritis.

Rationale 4: Herpes simplex lesions are not typically ulcerated.

Rationale 5: Herpes simplex lesions may be described as crusty.

Global Rationale: Herpes simplex lesions progress from vesicles to pustules, and then crusts. They are not typically itchy (pruritic). They are not often described as being ulcerated.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 251

 

Question 19

Type: MCSA

The nurse is reviewing documentation for a client from the previous shift. The documentation states, “+1 edema right lower leg.” Based on this data, what does the nurse expect when assessing this client?

  1. The presence of slight pitting, no obvious distortion.
  2. Deep pitting, obvious distortion.
  3. Pitting is obvious, extremities are swollen.
  4. Moderate amount of edema.

Correct Answer: 1

Rationale 1: Edema, or accumulation of fluid in the body’s tissues, is recorded as +1, +2, +3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no obvious distortion.

Rationale 2: Deep pitting with obvious distortion may be documented as +4 edema.

Rationale 3: Obvious pitting with swollen extremities may be described as +3 edema.

Rationale 4: A moderate amount of edema may be described as +2 to +3 edema.

Global Rationale: Edema, or accumulation of fluid in the body’s tissues, is recorded as +1, +2, +3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no obvious distortion.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 235

 

Question 20

Type: MCSA

During the assessment of a client’s integumentary status the nurse notes “vitiligo present bilateral hands.” Which analysis of this information is the most appropriate by the nurse?

  1. Nodules with ulcerations.
  2. Dark, asymmetrical colored patches.
  3. Grouped vesicles.
  4. Abnormal loss of melanin in patches.

Correct Answer: 4

Rationale 1: The term vitiligo does not indicate the presence of nodules with ulcerations.

Rationale 2: The term vitiligo does not indicate the presence of dark, asymmetrical colored patches.

Rationale 3: The term vitiligo does not indicate the presence of grouped vesicles.

Rationale 4: Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin.

Global Rationale: Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin. The term vitiligo does not indicate the presence of nodules with ulcerations; the presence of dark, asymmetrical colored patches; or the presence of grouped vesicles.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.2.1. Differentiate normal and abnormal variations in the body system observed during physical assessment.

Page Number: p. 242

 

Question 21

Type: MCSA

The nurse is conducting an admission assessment for a client and notes skin vitiligo, which is highly visible even from a distance. The client asks the nurse to place a “No Visitors” sign on the door. The client states, “I hate the way my skin looks. Some people just stare at me.” Which nursing diagnosis should be incorporated into the client’s plan of care?

  1. Defensive coping.
  2. Risk for loneliness.
  3. Deficient knowledge.
  4. Disturbed body image.

Correct Answer: 4

Rationale 1: Defensive coping is not the best nursing diagnosis to apply to this client. This client has a disturbed body image.

Rationale 2: The client does have a risk for loneliness but it is most likely due to the underlying disturbed body image.

Rationale 3: There is nothing to indicate that the client has a deficient knowledge. This client is suffering from a disturbed body image due to the skin’s appearance.

Rationale 4: This client has a visible skin disorder and is exhibiting signs that the client has a disturbed body image.

Global Rationale: A visible skin disorder may trigger psychosocial problems and a disturbed body image. This client has vitiligo, which is a skin condition. The client will exhibit patchy depigmented areas over some or all of the following body areas: face, neck, hands, feet, and body folds. A client with vitiligo may suffer a severe disturbance in body image.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

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: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 233

 

Question 22

Type: MCSA

The pediatric nurse conducts a follow-up phone call for a mother who was discharged with her newborn several days ago. The mother tells the nurse that she thinks her newborn is jaundice. Which question by the nurse will help to support this mother’s statement?

  1. Does your baby have tiny, white facial bumps?”
  2. “Does your baby’s skin and mucous membranes have a yellowish color?”
  3. “Does your baby have irregular red patches on the back of the neck?”
  4. “Does your baby have dark spots on the area above the buttock?”

Correct Answer: 2

Rationale 1: Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth.

Rationale 2: Yellowing of skin and mucous membranes in an infant who is 3–4 days old is a temporary form of jaundice called physiological jaundice, but may require treatment with fluids and phototherapy.

Rationale 3: Vascular markings are also called stork bites and may be located on the back of the neck.

Rationale 4: Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area.

Global Rationale: Yellowing of skin and mucous membranes in an infant who is 3–4 days old is a temporary form of jaundice called physiological jaundice, but may require treatment with fluids and phototherapy. Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth. Vascular markings are also called stork bites and may be located on the back of the neck. Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 214

 

Question 23

Type: MCSA

The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which action would be appropriate for the nurse in this situation?

  1. Use a bright lamp and a magnifying glass.
  2. Document “unable to assess” for skin changes.
  3. Assess the skin the same way you would inspect a client with lighter skin.
  4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms.

Correct Answer: 4

Rationale 1: A bright light may assist the nurse, but the nurse should inspect the client’s lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice.

Rationale 2: It is not appropriate to document that the nurse is unable to assess the client for jaundice.

Rationale 3: The nurse will not find it as useful to assess the client with darker skin in the same way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.

Rationale 4: Changes in skin color may be difficult to discover when assessing clients with dark skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.

Global Rationale: Changes in skin color may be difficult to discover when assessing clients with dark skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. A bright light may assist the nurse, but the nurse should inspect the client’s lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice. It is not appropriate to document that the nurse is unable to assess the client for jaundice. The nurse will not find it as useful to assess the client with darker skin in the same way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.

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: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 218

 

Question 24

Type: MCSA

The nurse is assessing the skin of a newborn and notes a bright red, raised lesion on the lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which response by the nurse is the most appropriate?

  1. “Your pediatrician can make a surgical referral for you.”
  2. “It really is not that noticeable.”
  3. “You should be happy that your baby is healthy overall.”
  4. “These types of lesions usually disappear by the time a child turns 10 years old.”

Correct Answer: 4

Rationale 1: There is no reason for the nurse to speak with the pediatrician regarding a surgical referral. These types of lesions usually disappear by the time a child turns 10 years old.

Rationale 2: The nurse should not indicate that the lesion is not that noticeable. The nurse should educate the mother about the lesion.

Rationale 3: The nurse should not state that the mother should be happy with the overall health of the newborn. The mother is concerned about the appearance of the lesion and should be educated about the lesion and its normal course.

Rationale 4: The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 10, and no intervention is needed.

Global Rationale: The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 10, and no intervention is needed. The nurse should educate the mother about the lesion. The mother does not require comments suggesting she should ignore the lesion or be happy that the infant does not have more serious problems. The nurse should not state that the mother should be happy with the overall health of the newborn. The mother is concerned about the appearance of the lesion and should be educated about the lesion and its normal course.

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: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 246

 

Question 25

Type: MCSA

The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client’s left arm. The client states, “I had a burn here a long time ago, but it seemed to keep on getting bigger.” Which term will the nurse use when documenting this finding in the client’s medical record?

  1. Ulcer.
  2. Keloid.
  3. Fissure.
  4. Scar.

Correct Answer: 2

Rationale 1: An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. This tissue is best described as a keloid.

Rationale 2: This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent.

Rationale 3: A fissure is a crack in the skin extending to the dermis. This tissue is best described as a keloid.

Rationale 4: A scar is connective tissue left after healing, but is flat and usually linear. This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent.

Global Rationale: This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. A fissure is a crack in the skin extending to the dermis. A scar is connective tissue left after healing, but is flat and usually linear. This tissue is best described as a keloid.

Cognitive Level: Understanding

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: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 244

 

Question 26

Type: MCSA

The nurse is caring for a client who had abdominal surgery several months ago. The client has verbalized concern that the scar from the surgery is purplish in color. Which response by the nurse is the most appropriate?

  1. “Having a scar is unavoidable.”
  2. “The color is normal and will fade with time.”
  3. “You can have plastic surgery to remove the scar later.”
  4. “You should be glad your surgery was a success.”

Correct Answer: 2

Rationale 1: The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar.

Rationale 2: New scars may be red or purple in color and will fade to silvery or white with time.

Rationale 3: The nurse should not suggest that the plastic surgery is an alternative to dealing with the scar. The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar.

Rationale 4: The nurse should not express disapproval regarding the client’s concerns. The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar.

Global Rationale: New scars may be red or purple in color and will fade to silvery or white with time. The nurse should not suggest plastic surgery, nor use statements that infer disapproval that the client is asking about the scar.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

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: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 244

 

Question 27

Type: MCSA

During the assessment of an older adult client’s skin, the nurse notes small areas of hyperpigmentation on the dorsal aspect of the client’s hands. The client states, “I’ve been getting more of these big freckles as I get older.” Which term will the nurse use when documenting this finding in the medical record?

  1. Senile lentigines.
  2. Cherry angiomas.
  3. Cutaneous tags.
  4. Cutaneous horns.

Correct Answer: 1

Rationale 1: The nurse is describing “liver spots” or areas of hyperpigmentation over the backs of the client’s hands.

Rationale 2: Cherry angiomas are small, bright red spots common in older adults.

Rationale 3: Cutaneous tags may appear on the neck and upper chest.

Rationale 4: Cutaneous horns may occur on any part of the face.

Global Rationale: The nurse is describing “liver spots” or areas of hyperpigmentation over the backs of the client’s hands. Cherry angiomas are small, bright red spots common in older adults. Cutaneous tags may appear on the neck and upper chest. Cutaneous horns may occur on any part of the face.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 216

 

Question 28

Type: MCSA

The nurse is planning to assess the integumentary status for an African American client. Which client statement supports the nurse’s documentation that the client is experiencing pallor?

  1. “The whites of my eyes don’t look as white anymore; they have a little bit of a yellow cast to them.”
  2. “My nails look a little bit bluish.”
  3. “My nails are bright red.”
  4. “My palms and the inside of my mouth look really pale.”

Correct Answer: 4

Rationale 1: The client who states that the sclerae appear yellowish may have become jaundiced.

Rationale 2: Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae in clients with darker skin color.

Rationale 3: The client with bright red nails may be experiencing a sign of polycythemia.

Rationale 4: The client with pale palms and mucous membranes may have developed pallor.

Global Rationale: The client with pale palms and mucous membranes may have developed pallor. The client who states that the sclerae appear yellowish may have become jaundiced. Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae in clients with darker skin color. The client with bright red nails may be experiencing a sign of polycythemia.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 217

 

Question 29

Type: MCMA

The nurse is preparing an educational program regarding the objectives listed in Healthy People 2020. Which statements in the presentation support these objectives?

Standard Text: Select all that apply.

  1. African American females often require information regarding gentle hair and scalp care.
  2. Infants have difficulty regulating their own body temperatures.
  3. Older clients have increased sweat gland activity.
  4. Clients with diabetes mellitus have an increased risk for skin breakdown.
  5. Clients should monitor their moles for any changes, regardless of their age.

Correct Answer: 1, 2, 4, 5

Rationale 1: Nurses should provide African American women with information about the risks associated with chemical treatments, excessive combing, and pulling to braid fragile hair.

Rationale 2: Infants’ skin lacks the ability to contract. Therefore, they cannot shiver and do not perspire, limiting thermal regulation. Infants require clothing that is appropriate for the external temperature and environment.

Rationale 3: Older clients are prone to reduced sweat gland activity, which can result in dry skin.

Rationale 4: Clients with diabetes are at increased risk for problems with the skin and with healing of existing skin problems.

Rationale 5: All clients should monitor moles for any changes in color, size, or texture.

Global Rationale: Nurses should provide African American women with information about the risks associated with chemical treatments, excessive combing, and pulling to braid fragile hair. Infants’ skin lacks the ability to contract. Therefore, they cannot shiver and do not perspire, limiting thermal regulation. Infants require clothing that is appropriate for the external temperature and environment. Clients with diabetes are at increased risk for problems with the skin and with healing of existing skin problems. All clients should monitor moles for any changes in color, size, or texture. Older clients are prone to reduced sweat gland activity, which leads to drier skin.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations.

NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.7: Relate integumentary health to Healthy People 2020 objectives.

MNL Learning Outcome:

Page Number: pp. 228–230

 

Question 30

Type: MCSA

While performing a skin assessment for a client, the nurse notes that the client becomes pales and diaphoretic. The client’s vital signs have remained stable since the beginning of the examination: blood pressure 138/76 mmHg, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which is the priority response by the nurse?

  1. The nurse immediately raises the client’s head of bed.
  2. The nurse asks the client, “Are you feeling anxious during this assessment?”
  3. The nurse immediately notifies the client’s healthcare provider.
  4. The nurse provides the client with ½ cup of orange juice.

Correct Answer: 2

Rationale 1: The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable. The nurse does not need to alter the position of the client’s head of bed.

Rationale 2: Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the client’s level of anxiety and acknowledging the client’s anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable.

Rationale 3: The nurse does not need to notify the client’s healthcare provider. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable.

Rationale 4: The nurse does not need to provide the client with orange juice. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The client’s serum glucose level should be assessed if hypoglycemia was suspected.

Global Rationale: Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the client’s level of anxiety and acknowledging the client’s anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client’s vital signs have remained stable. The nurse does not need to alter the position of the client’s head of bed. The nurse does not need to notify the client’s healthcare provider. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The client’s serum glucose level should be assessed if hypoglycemia was suspected.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.8: Apply critical thinking to the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 231

 

Question 31

Type: MCMA

The nurse is preparing a client for a detailed assessment of the integumentary system. Which statements by the nurse are useful to prepare the client for this examination?

Standard Text: Select all that apply.

  1. “Please remove all jewelry so that I can conduct a full assessment.”
  2. “I will turn the temperature down in the exam room before we begin.”
  3. “Use this blanket to cover up until we are ready to begin.”
  4. “I will be touching your skin as part of the process.”
  5. “I will need you to take off your head dress for the entire examination.”

Correct Answer: 1, 3, 4

Rationale 1: Jewelry can often hinder the nurse’s ability to conduct a complete skin assessment. This statement is appropriate to prepare the client for the exam.

Rationale 2: The temperature of the room should be warm, yet comfortable. Turning down the temperature without first asking the client’s input is not appropriate.

Rationale 3: It is often necessary to expose certain areas of the skin during the assessment process. A drape should be provided to the client to cover all areas that are not being assessed. This action is appropriate prior to beginning the exam.

Rationale 4: Palpating the skin is part of an integumentary assessment. It is important to state this to the client before the examination. This statement is appropriate to prepare the client for the exam.

Rationale 5: While it may be necessary for the client’s head dress to be removed during certain portions of the exam, it is not necessary for the entire examination process. This statement does not take the client’s cultural background into consideration and is not appropriate.

Global Rationale: Jewelry can often hinder the nurse’s ability to conduct a complete skin assessment. This statement is appropriate to prepare the client for the exam. It is often necessary to expose certain areas of the skin during the assessment process. A drape should be provided to the client to cover all areas that are not being assessed. This action is appropriate prior to beginning the exam. Palpating the skin is part of an integumentary assessment. It is important to state this to the client before the examination. The temperature of the room should be warm, yet comfortable. Turning down the temperature without first asking the client’s input is not appropriate. While it may be necessary for the client’s head dress to be removed during certain portions of the exam, it is not necessary for the entire examination process. This statement does not take the client’s cultural background into consideration and is not appropriate.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence.

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: Conduct population-based transcultural health assessments and interventions.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.4: Explain patient preparation for assessment of the skin, hair, and nails.

MNL Learning Outcome: 6.1.3. Utilize the appropriate techniques, tools, and tests to perform a focused physical assessment.

Page Number: p. 231