EssentialHealthAssessment2ndEditionThompsonTestBank v v v v v v v
Chapter1.Understanding Health Assessment
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Question 1 v
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The nurse is obtaining a health history from a client who reports that he is healthy and has no health
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concerns.As partofthehealth history,thenursedocuments thattheclientreported thathe hashigh
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bloodpressureandsuffersfromalegulcerthat remainsunhealedafter6 months.Which of the
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v following statements would be the best choice for the nurse to use at this point in the interview?
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1. I feel that you may be in denial about your health status.
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2. Tell me about your definition of being healthy.
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3. Do you understand what hypertension is?
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4. Is there anything else you are not telling me?
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CorrectAnswer:2 v v
Rationale1: Moreinformationwould beneeded before thenursecould attributetheclients viewpoint
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v as denial or lack of knowledge.
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Rationale 2: A client will have his or her own definition of health, illness, and wellness. The
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v individuals concept of health and wellness is influenced by many factors, including age, gender,
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v race,family,culture,religion,socioeconomicconditions,environment,previousexperiences,and
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v self-expectations.
Rationale3: The clients history ofhypertension is avalid area requiring furtherinvestigation but the
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v nurse must first ascertain the clients definition of healthy.
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,Rationale4:Thereisnotenoughinformationtodeterminetheclientswithholdingofinformation to the
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v nurse.
Global Rationale: A client will have his or her own definition of health, illness, and wellness. The
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v individuals concept of health and wellness is influenced by many factors, including age, gender,
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v race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and
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v self-expectations. More information would be needed before the nurse could attributetheclients
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viewpoint as denialorlack of knowledge. Theclientshistoryofhypertension is a valid area requiring
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v further investigation but the nurse must first ascertain the clients definition of healthy. There is also
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not enough information to determine the clients withholding of information to the nurse.
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Cognitive Level: Analyzing v v
ClientNeed: Health Promotion andMaintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment v v v v
LearningOutcome:1.4:Identify thefactors toconsiderinhealth assessment
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Question 2 v
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Thenurseisdocumentingintheclientsmedicalrecordandwishes touseSOAPcharting.The nurse
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v includes which of the following under the assessment category?
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1. Theclients blood pressure was 177/93.
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2. The recent loss of employment and insurancehave prevented theclient from being able to
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afford prescription medications.
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3. The client reports having lost her job and insurance 3 months ago.
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,4. Referralshavebeen madetosocialservicestodeterminefinancialassistanceprograms
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available.
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CorrectAnswer:2 v v
Rationale1: ThisistheOcomponent, objective data. v v v v v v v v
Rationale2: TheAcomponent oftheSOAP notereferstoconclusions drawn from the subjective
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v and objective data obtained.
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Rationale3: Thisis subjective data. v v v v v
Rationale4:Thisisthe P component, plan. v v v v v v v
Global Rationale: The A component of the SOAP note refers to conclusions drawn from the
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v subjectiveandobjectivedataobtained. Theclientsrecentlossofemploymentandthepotential that
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v this was a contributing factor in the inability to afford medications is an example of a conclusion.
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v The clients reported blood pressure would be an example of objective data.
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Objective data is information that can be measured by the examiner. Blood pressure is not an
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v exampleofsubjective information noris ita conclusion. Theclientsreported lossof employment and
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insurance is an example of subjective data. The statement does not include conclusions as to the results
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ofthese events. Makingreferrals to socialservices is an example of an intervention. It is not a
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v conclusion.
Cognitive Level: Applying v v
ClientNeed: Health Promotion andMaintenance
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Client Need Sub: v v
Nursing/Integrated Concepts: Nursing Process: Assessment v v v v
LearningOutcome:1.4:Identify thefactors toconsiderinhealth assessment.
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Question 3 v
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, The nurse is presenting a workshop on wellness and health promotion and the initiatives of
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v Healthy People 2020 as a resource for this topic. After the session, which of the following
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v statements by a participant indicates an understanding concerning the initiatives proposed?
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1. Itwill allowhealth careproviders tolobby legislators for more funding.
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2. TheprimarygoalofHealthyPeople2020istoassisthealthcareprovidersindeterminingrisk
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v factors for premature birth. v v v
3. HealthyPeople2020seeks topromoteshealth, prevent illness,disability,and premature death.
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4. Theinitiatives willoutline standardsof carefor providersin managing diseases.
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CorrectAnswer:3 v v
Rationale 1:Healthcareproviders andother persons interested in programs to promote health have
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found the document to be a useful source of information in their efforts to gain funding.
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Rationale 2: The Healthy People 2020 initiative is a 10-year strategy intended to promote health,
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preventillness,disability,andprematuredeath.Thedocumentidentifiesleadinghealth indicators that
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reflect public health concerns. Risk factors for premature birth may be part of those health
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v indicators, but the scope of the document covers broad areas of concern.
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Rationale3:TheHealthyPeople2020initiativeisa10-yearstrategyintendedtopromotehealth, prevent
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v illness, disability, and premature death.
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Rationale4: Standardsof care in disease management is not a componentof the document.
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Global Rationale: The Healthy People 2020 initiative is a 10-year strategy intended to promote
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v health, prevent illness, disability, and premature death. The document identifies leading health
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v indicators that reflect public health concerns. Risk factors for premature birth may be part of those
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health indicators, but the scopeof thedocument covers broad areas of concern. Health care providers
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andotherpersonsinterestedinprograms topromotehealthhavefoundthedocument to be a useful
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v source of information in their efforts to gain funding. Standards of care in disease management is
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v not a component of the document.
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