Test Bank For Health and Physical Assessment In Nursing, 2nd Edition

Name: Test Bank For Health and Physical Assessment In Nursing, 2nd Edition
Brand: Academic Documents Platform
Price: 20 USD
Availability: InStock
Author: David Miller

Test Bank For Health and Physical Assessment In Nursing, 2nd Edition is the key to mastering your exam with practice questions, answers, and expert strategies.

David Miller

Contributor

4.8

2 days ago

Preview (16 of 850)

Chapter 1
D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 1
Question 1
Type: MCSA
The nurse is obtaining a health history from a client who reports that he is healthy and has no health
concerns. As part of the health history, the nurse documents that the client reported that he has high
blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. Which of the
following statements would be the best choice for the nurse to use at this point in the interview?
1. “I feel that you may be in denial about your health status.”
2. “Tell me about your definition of being healthy.”
3. “Do you understand what hypertension is?”
4. “Is there anything else you are not telling me?”
Correct Answer: 2
Rationale 1: More information would be needed before the nurse could attribute the client’s
viewpoint as denial or lack of knowledge.
Rationale 2: A client will have his or her own definition of health, illness, and wellness. The
individual’s concept of health and wellness is influenced by many factors, including age, gender,
race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and
self-expectations.
Rationale 3: The client’s history of hypertension is a valid area requiring further investigation but
the nurse must first ascertain the client’s definition of healthy.
Rationale 4: There is not enough information to determine the client’s withholding of information to
the nurse.
Global Rationale: A client will have his or her own definition of health, illness, and wellness. The
individual’s concept of health and wellness is influenced by many factors, including age, gender,
race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and
self-expectations. More information would be needed before the nurse could attribute the client’s
viewpoint as denial or lack of knowledge. The client’s history of hypertension is a valid area
requiring further investigation but the nurse must first ascertain the client’s definition of healthy.
There is also not enough information to determine the client’s withholding of information to the
nurse.
Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment
Question 2
Type: MCSA
The nurse is documenting in the client’s medical record and wishes to use SOAP charting. The nurse
includes which of the following under the assessment category?
1. The client’s blood pressure was 177/93.
2. The recent loss of employment and insurance have prevented the client from being able to afford
prescription medications.
3. The client reports having lost her job and insurance 3 months ago.
4. Referrals have been made to social services to determine financial assistance programs available.
Correct Answer: 2
Rationale 1: This is the “O” component, objective data.
Rationale 2: The “A” component of the SOAP note refers to conclusions drawn from the subjective
and objective data obtained.
Rationale 3: This is subjective data.
Rationale 4: This is the “P” component, plan.
Global Rationale: The “A” component of the SOAP note refers to conclusions drawn from the
subjective and objective data obtained. The client’s recent loss of employment and the potential that
this was a contributing factor in the inability to afford medications is an example of a conclusion.
The client’s reported blood pressure would be an example of objective data. Objective data is
information that can be measured by the examiner. Blood pressure is not an example of subjective
information nor is it a conclusion. The client’s reported loss of employment and insurance is an
example of subjective data. The statement does not include conclusions as to the results of these
events. Making referrals to social services is an example of an intervention. It is not a conclusion.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 3

Type: MCSA
The nurse is presenting a workshop on wellness and health promotion and the initiatives of Healthy
People 2020 as a resource for this topic. After the session, which of the following statements by a
participant indicates an understanding concerning the initiatives proposed?
1. “It will allow health care providers to lobby legislators for more funding.”
2. “The primary goal of Healthy People 2020 is to assist health care providers in determining risk
factors for premature birth.”
3. “Healthy People 2020 seeks to promotes health, prevent illness, disability, and premature death.”
4. “The initiatives will outline standards of care for providers in managing diseases.”
Correct Answer: 3
Rationale 1: Health care providers and other persons interested in programs to promote health have
found the document to be a useful source of information in their efforts to gain funding.
Rationale 2: The Healthy People 2020 initiative is a 10-year strategy intended to promote health,
prevent illness, disability, and premature death. The document identifies leading health indicators
that reflect public health concerns. Risk factors for premature birth may be part of those health
indicators, but the scope of the document covers broad areas of concern.
Rationale 3: The Healthy People 2020 initiative is a 10-year strategy intended to promote health,
prevent illness, disability, and premature death.
Rationale 4: Standards of care in disease management is not a component of the document.
Global Rationale: The Healthy People 2020 initiative is a 10-year strategy intended to promote
health, prevent illness, disability, and premature death. The document identifies leading health
indicators that reflect public health concerns. Risk factors for premature birth may be part of those
health indicators, but the scope of the document covers broad areas of concern. Health care providers
and other persons interested in programs to promote health have found the document to be a useful
source of information in their efforts to gain funding. Standards of care in disease management is not
a component of the document.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.2: Discuss the importance of Healthy People 2020 and its relevance to health
assessment.
Question 4

Type: MCSA
The nurse is developing a handout for clients in a healthcare provider’s office. The nurse would
include which of the following focus areas in this handout to emphasize current changes in the health
care delivery system?
1. Class recommendations for diabetics concerning insulin administration A2.Guidelines from the
Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of
toxins
2. Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of disease,
eradicating the use of toxins
3. Resources available to treat chronic pain
4. Class listings for exercise classes available in the community
Correct Answer: 4
Rationale 1: Symptom management, illness care, and pain management are addressed by the health
care delivery system but are not the primary focus, as clients are taking a more active role in
managing their own care.
Rationale 2: Management of outbreaks of disease is a function of governmental organizations and
health care providers in the community, but is not a focus of individual care.
Rationale 3: Symptom management, illness care, and pain management are addressed by the health
care delivery system but are not the primary focus, as clients are taking a more active role in
managing their own care.
Rationale 4: The focus of health care in the United States today is wellness, prevention of disease,
health promotion and health maintenance, for which a listing of exercise classes is appropriate.
Global Rationale: The focus of health care in the United States today is wellness, prevention of
disease, health promotion, and health maintenance, for which a listing of exercise classes is
appropriate. Symptom management, illness care, and pain management are addressed by the health
care delivery system but are not the primary focus, as clients are taking a more active role in
managing their own care. Management of outbreaks of disease is a function of governmental
organizations and health care providers in the community, but is not a focus of individual care.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1.8: Discuss the elements of a teaching plan.

Question 5
Type: MCSA
The nurse is admitting a client to the acute care facility. The health history form has a place for
recording subjective data. The nurse understands that primary subjective data should be obtained
from which of the following sources?
1. The client’s physical assessment
2. The client’s self-reports
3. The client’s healthcare provider
4. The client’s significant other
Correct Answer: 2
Rationale 1: The physical assessment will be recorded as objective data.
Rationale 2: Subjective data are gathered from the interview. The interview includes the health
history and focused interview. Data will come from primary and secondary sources.
Rationale 3: The client’s healthcare provider and significant other may contribute in the data
collection process. The information obtained from friends and family members is considered
subjective. This source of information is termed secondary.
Rationale 4: The client’s significant other may contribute in the data collection process but that input
is classified as subjective.
Global Rationale: Subjective data are gathered from the interview. The interview includes the health
history and focused interview. Data will come from primary and secondary sources. The client is
considered the primary source of subjective information. Family members and healthcare providers
are examples of secondary sources of subjective information. The physical assessment will be
recorded as objective data.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment.
Question 6
Type: MCSA
The nurse is reviewing a client’s medical records and notes various forms of information. The nurse
understands that which of the following are subjective data?
1. The client states, “My abdomen hurts on the left side after eating.”

Loading page 6...

2. The nurse notes the client’s abdomen is tender on the left side during palpation.
3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen.
4. The client’s hemoglobin is 14.1 gm/dL.
Correct Answer: 1
Rationale 1: Subjective reports by the client are those feelings or symptoms that cannot be observed
by others, of which “My abdomen hurts” is an example.
Rationale 2: Physical examination findings, laboratory analysis reports and radiographic findings are
objective data.
Rationale 3: Physical examination findings, laboratory analysis reports and radiographic findings are
objective data.
Rationale 4: Physical examination findings, laboratory analysis reports and radiographic findings are
objective data.
Global Rationale: Subjective reports by the client are those feelings or symptoms that cannot be
observed by others. Objective reports are those factors that are based upon observations of others.
Physical examination findings, laboratory analysis reports, and radiographic findings are objective
data.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 7
Type: MCSA
The nurse is reviewing a client’s medical records and notes various information. The nurse
understands that which of the following is an example of objective data?
1. “I hurt my head.”
2. “I am 6 years old and I’m here because I fell.”
3. “Six-year-old Hispanic female sitting on examination table holding a towel to her forehead.”
4. “Client states that she fell at the playground.”
Correct Answer: 3
Rationale 1: Statements the client makes are subjective data.
Rationale 2: Statements the client makes are subjective data.

Loading page 7...

Rationale 3: Objective data are data that can be observed or measured by the nurse. The nurse can
see the child holding the towel to her head and can use her birth date to determine her age.
Rationale 4: Statements the client makes are subjective data.
Global Rationale: Objective data are data that can be observed or measured by the nurse. The nurse
can see the child holding the towel to her head and can use her birth date to determine her age.
Statements the client makes are subjective data.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 8
Type: MCSA
The nurse is evaluating the plan of care and notes that none of the goals have been met for the client
with impaired gas exchange. What should the nurse do next in this situation?
1. Report the lack of achievement of the goals to the healthcare provider.
2. Review the data and modify the plan.
3. Reformulate the nursing diagnosis to a more realistic one.
4. Request a consult for the client to be seen by a pulmonologist.
Correct Answer: 2
Rationale 1: Reporting the lack of achievement of the goals to the healthcare provider is not
appropriate, though reporting undesirable client physiologic responses may be.
Rationale 2: The plan of care should be evaluated periodically, at the established time frames, to
determine achievement of the goals. If goals are not achieved, then the data need to be further
assessed and the plan modified.
Rationale 3: Reformulating the nursing diagnosis to a more realistic one is not the best course of
action as the diagnosis established came from subjective and objective data specific to that diagnosis.
Rationale 4: There are no data to support the need for additional medical consultations.
Global Rationale: The plan of care should be evaluated periodically, at the established time frames,
to determine achievement of the goals. If goals are not achieved, then the data need to be further
assessed and the plan modified. Reporting the lack of achievement of the goals to the healthcare
provider is not appropriate, though reporting undesirable client physiologic responses may be.
Reformulating the nursing diagnosis to a more realistic one is not the best course of action as the

Loading page 8...

diagnosis established came from subjective and objective data specific to that diagnosis. There are no
data to support the need for additional medical consultations.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1.5: Define the steps of the nursing process.
Question 9
Type: MCSA
The community health nurse is preparing to conduct a program for a group of nursing students
concerning health and wellness. Which of the following statements by a participant indicates the
most comprehensive and accurate understanding of health?
1. “Health is the absence of illness, disease, and symptoms.”
2. “Health is a state of well-being and the use of every power the person possesses to the fullest
extent.”
3. “Health is the state when a person is viewed as a holistic being.”
4. “Health is a state of complete physical, mental, and social well-being.”
Correct Answer: 4
Rationale 1: Health is much more than the absence of illness and disease.
Rationale 2: Defining health as a state of well-being is limiting as it does not encompass the
elements of an individual’s being such as physical, mental, and social.
Rationale 3: While health does require a holistic approach, this definition does not explore the
elements with the same clarity of the correct answer.
Rationale 4: Health is defined as a state of complete physical, mental, and social well-being (WHO,
1947).
Global Rationale: Health is defined as a state of complete physical, mental, and social well-being
(WHO, 1947). Health is much more than the absence of illness and disease. Defining health as a state
of well-being is limiting as it does not encompass the elements of an individual’s being such as
physical, mental, and social. While health does require a holistic approach, this definition does not
explore the elements with the same clarity of the correct answer.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:

Loading page 9...

Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1.1: Discuss the various definitions of health.
Question 10
Type: MCSA
The nurse is caring for a client who is recovering from abdominal surgery. When determining the
best goal statement for the client concerning level of pain, which of the following is most
appropriate?
1. The client will verbalize pain relief using an intensity rating in 4 hours.
2. The client will state that he feels fine in 4 hours.
3. The nurse will observe fewer signs of pain in the client’s demeanor.
4. The nurse will reevaluate the client’s pain level every 2 hours.
Correct Answer: 1
Rationale 1: The goal statement is directly related to the nursing diagnosis. Goal statements are
stated in a positive fashion, and have measurable criteria.
Rationale 2: This statement is not related directly related to the diagnosis and is not measurable.
Rationale 3: A goal statement must be reflective of client activities. This is an incorrect answer
because it reflects activities of the nurse and not the client.
Rationale 4: A goal statement must be reflective of the client’s activities. This is an incorrect answer
because it reflects activities of the nurse and is not client directed. Although there is a time frame
listed it is not correct as it is related to nursing actions.
Global Rationale: The goal statement is directly related to the nursing diagnosis. Goal statements
are stated in a positive fashion, and have measurable criteria. Verbalization of the client of pain relief
using a rating scale within a specified time period is an appropriately formatted, measurable
statement. Statements by the client indicating he is feeling fine is not reflective of a measurable
criteria. Statements indicating actions by the nurse are not correctly formatted goals for the client.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1.5: Define the steps of the nursing process.
Question 11
Type: MCSA

Loading page 10...

The nurse is developing the plan of care for a client who is recovering from abdominal surgery.
When planning interventions the nurse recognizes which of the following will best meet the needs of
the client experiencing pain?
1. The healthcare provider will prescribe additional analgesics.
2. The client will have reduced pain after administration of analgesics.
3. The client will vocalize reduced levels of pain within 3 hours.
4. Assist the client with guided imagery to manage pain levels.
Correct Answer: 4
Rationale 1: The prescribing of additional analgesics does not determine the characteristics of the
pain and does not offer patient-driven information.
Rationale 2: This is a goal statement, not an intervention.
Rationale 3: This is a goal statement, not an intervention.
Rationale 4: Nursing interventions, such as assisting the client with guided imagery, are geared to
assist in meeting client goals. The interventions are derived from the second part of the diagnosis,
which is the etiology. The defining characteristics provide the background support for the diagnosis.
The diagnostic label is global and requires specification before attempting to determine a goal. The
client’s stated wishes are an important component of planning, and may be included in the list of
interventions as appropriate. The interventions are based upon nursing actions.
Global Rationale: Nursing interventions are geared to assist in meeting client goals. The
interventions are derived from the second part of the diagnosis, which is the etiology. The defining
characteristics provide the background support for the diagnosis. The diagnostic label is global and
requires specification before attempting to determine a goal. The client’s stated wishes are an
important component of planning, and may be included in the list of interventions as appropriate. The
interventions are based upon nursing actions. The prescribing of additional analgesics does not
determine the characteristics of the pain and does not offer patient driven information. The reduction
of pain and vocalization of pain levels within 3 hours are goal statements, not interventions.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1.6: Describe the critical thinking process with relevance to health assessment.
Question 12
Type: MCSA

Loading page 11...

The nursing instructor is discussing Healthy People 2020 with a group of nursing students. One of
the students questions the instructor how this work will impact hospitalization. The best response by
the nursing instructor would be:
1. “Healthy People 2020 is a tool for the healthcare providers to offer information to their clients.”
2. “Healthy People 2020 seeks to improve health and prevent illness, disability, and premature
death.”
3. “The purpose of Healthy People 2020 is to reduce health care costs for hospitalized clients.”
4. “Healthy People 2020 is seen as a tool by hospitals to reduce length of stay.”
Correct Answer: 2
Rationale 1: Healthy People 2020 is a resource tool for all health care professionals but its purpose
is not to provide patient education between the healthcare provider and client.
Rationale 2: Healthy People 2020 presents a 10-year strategy with objectives intended to enhance
health and prevent illness, disability, and premature death.
Rationale 3: Reduction of hospital costs is the not the primary purpose of Healthy People 2020.
Rationale 4: Reduction of length of stay is the not the primary purpose of Healthy People 2020.
Global Rationale: Healthy People 2020 presents a 10-year strategy with objectives intended to
enhance health and prevent illness, disability, and premature death. Healthy People 2020 is a
resource tool for all health care professionals but its purpose is not to provide patient education
between the healthcare provider and client. Reduction of hospital costs is the not the primary purpose
of Healthy People 2020.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1.2: Discuss the importance of Healthy People 2020.
Question 13
Type: MCSA
The recent graduate nurse is orienting to the medical surgical care unit. The graduate nurse has
prepared a nursing care plan for a client admitted for exacerbation of ulcerative colitis. The goal
statement is, “The client will resume normal bowel elimination patterns.” The graduate nurse has
asked the charge nurse to review the care plan. What action by the charge nurse is indicated?
1. Express to the new nurse that the goal statement meets criteria.
2. Explain to the new nurse that the lack of time frame makes the goal inappropriate.

Loading page 12...

3. Express to the new nurse that the goal statement is not reflective of the client’s admitting
diagnosis.
4. Accept the care plan for inclusion into the client’s medical record as it is accurate.
Correct Answer: 2
Rationale 1: This goal statement does not meet criteria as it lacks a time frame.
Rationale 2: Time frames are an important component of goal statements and provide guidelines for
when to evaluate the achievement of the goal.
Rationale 3: The defining characteristics of the diagnosis and the etiology of the diagnosis are
components of the diagnostic statement.
Rationale 4: This goal statement does not meet criteria as it lacks a time frame.
Global Rationale: This goal statement does not meet criteria as it lacks a time frame. Time frames
are an important component of goal statements and provide guidelines for when to evaluate the
achievement of the goal. The defining characteristics of the diagnosis and the etiology of the
diagnosis are components of the diagnostic statement. The nurse’s role in achieving the goal is not a
component of the goal statement.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1.5: Define the steps of the nursing process.
Question 14
Type: MCMA
The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus
Aureus (MRSA). Which of the following are appropriate goals of the initial health assessment?
Standard Text: Select all that apply.
1. Determine the client’s current state of health and ongoing health-promotion activities.
2. Predict risks to current health status.
3. Use only objective data to determine client allergies.
4. Determine how frequently the client is able to change positions.
5. Identify health-promoting activities.
Correct Answer: 1,5

Loading page 13...

Rationale 1: Determine the client’s current state of health and ongoing health-promotion
activities: Health assessment goals are to determine the client’s current state of health and ongoing
health-promotion activities.
Rationale 2: Predict risks to current health status: Health assessment activities are used to predict
risks to health, and identify health status both current and future. This includes physical, social,
cultural, environmental, and emotional factors including wellness behaviors, illness signs and
symptoms, client strengths and weaknesses, and risk factors.
Rationale 3: Use only objective data to determine client allergies. The initial health assessment
includes both objective and subjective information.
Rationale 4: Determine how frequently the client is able to change positions. The initial health
assessment includes both objective and subjective information and seeks to determine the potential
an individual has to implement health-promoting activities. Health assessment activities are used to
predict risks to health, and identify health status. This includes physical, social, cultural,
environmental, and emotional factors including wellness behaviors, illness signs and symptoms,
client strengths and weaknesses, and risk factors. The ability of the client to change positions is not a
part of the initial health assessment. .
Rationale 5: Identify health-promoting activities. The health assessment seeks to determine the
potential an individual has to implement health-promoting activities.
Global Rationale: Health assessment goals are to determine the client’s current state of health and
ongoing health-promotion activities. The initial health assessment includes both objective and
subjective information and seeks to determine the potential an individual has to implement health-
promoting activities. Health assessment activities are used to predict risks to health, and identify
health status. This includes physical, social, cultural, environmental, and emotional factors including
wellness behaviors, illness signs and symptoms, client strengths and weaknesses, and risk factors.
The initial health assessment does not include using objective data to determine client allergies and is
not part of the initial health assessment.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.5: Define the steps of the nursing process.
Question 15
Type: MCSA

Loading page 14...

While the nurse assesses a client who is hospitalized for an acute exacerbation of chronic obstructive
pulmonary disease (COPD), the client becomes very short of breath. The nurse recognizes the need
to stop the assessment to initiate respiratory support interventions. This is an example of which phase
of critical thinking?
1. Collection of information
2. Evaluation
3. Generation of alternatives
4. Analysis of the situation
Correct Answer: 4
Rationale 1: Collection of information is the initial step in the process. During this phase the nurse
will assess available information.
Rationale 2: Evaluation is the final step in the process. During evaluation the nurse will determine
the effectiveness of actions taken.
Rationale 3: When generating alternatives for action the nurse will use critical thinking skills to
determine available options for action.
Rationale 4: The nurse in the scenario will need to employ assessment skills to review and analyze
the situation. The analysis will provide the nurse with the understanding of what the best plan of
action will be.
Global Rationale: The nurse in the scenario will need to employ assessment skills to review and
analyze the situation. The analysis will provide the nurse with the understanding of what the best
plan of action will be. Collection of information is the initial step in the process. During this phase
the nurse will assess available information. Evaluation is the final step in the process. During
evaluation the nurse will determine the effectiveness of actions taken. When generating alternatives
for action the nurse will use critical thinking skills to determine available options for action.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1.6: Describe the critical thinking process with relevance to health assessment.
Question 16
Type: MCMA

Loading page 15...

The nurse is completing an admission assessment. The assessment form allows for the separation of
subjective and objective data. Distinguish which of the following are examples of subjective data
utilized by the nurse.
Standard Text: Select all that apply.
1. The client’s mother informs the nurse that her daughter has not been sleeping due to pain.
2. The client states, “I have pain in my belly that is 7 out of 10.”
3. Abdominal assessment reveals a firm, hard abdomen.
4. The client is weak and looks very pale.
5. The client appears nervous during the data collection period.
Correct Answer: 1,2
Rationale 1: The client’s mother informs the nurse that her daughter has not been sleeping due
to pain. Subjective data is information the client experiences and communicates to the nurse. This
information can be provided by either the client or other individuals.
Rationale 2: The client states, “I have pain in my belly that is 7 out of 10.” Subjective data is
information the client experiences and communicates to the nurse.
Rationale 3: Abdominal assessment reveals a firm, hard abdomen. Data that are observed by the
examiner are termed objective data.
Rationale 4: The client is weak and looks very pale. Data that are observed by the examiner are
termed objective data.
Rationale 5: The client appears nervous during the data collection period. Data that are observed
by the examiner are termed objective data.
Global Rationale: Subjective data is information the client experiences and communicates to the
nurse. This information can be provided by either the client or other individuals. Primary subjective
data is information the client experiences and communicates to the nurse. Information provided by
family is also considered subjective but is termed secondary. Assessment data that are observed by
the examiner are termed objective data. Reports by the client’s mother are considered secondary
subjective information. The statements made by the client are referred to as primary subjective data.
The characteristics of the abdomen, the client’s strength level, color, and psychosocial assessment are
termed objective data.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment

Loading page 16...

13 more pages available. Scroll down to load them.

Preview Mode

100%

Study Now!

XY-Copilot AI

Unlimited Access

Secure Payment

Instant Access

24/7 Support

Document Chat

Document Details

Subject

Nursing

Test Bank For Health and Physical Assessment In Nursing, 2nd Edition

Study Now!

Document Details

Related Documents

The Evolution of Nursing Science: Key Theories and Their Impact on Patient Care

Pediatric Gastrointestinal Disorders: Pathophysiology, Clinical Manifestations, Treatments, and Nursing Management

NUR/443 Cost and Effects of Performance Feedback and Nurse Case Management

NRS-427V Week 2 Epidemiology and Communicable Diseases Paper

NRS-427V Week 2 Epidemiology Paper

Chamberlain College of Nursing NR503 Population Health, Epidemiology, & Statistical Principles

NR660 Capstone Chamberlain College of Nursing Evaluation of epidemiology Problem

NUR440 Case Study 5 Acute Renal Failure

Nursing Entrance Exams Test Easy (2019)

Test Bank For Principles Of Pediatric Nursing: Caring For Children, 6th Edition

Company

Explore

Study Tools