2nd Health Promotion and Disease Prevention Review
Blood pressure is 170/80 mm Hg.
The client appears anxious.
The client
... [Show More] has diminished reflexes in the legs.
Correct!
The client states that he has a rash.
Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results.
Test-Taking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain during the physical examination. Review: the difference between subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence
1 / 1 pts
A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data?
The last menstrual period was 30 days ago.
The client is allergic to strawberries.
The client takes acetaminophen (Tylenol) for headaches.
Correct!
A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen.
Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data.
Test-Taking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain from the client during the health history. Review: the difference between subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp.
2, 55). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence
Question 3
1 / 1 pts
A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client?
Episodic
Correct!
Complete
Follow-up
Emergency
Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Noting the words “initial home visit” in the question will direct you to the correct option. Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis: Saunders. Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Technology and Informatics
HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology
Question 4
1 / 1 pts
A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which?
A complete (total health) database
Correct!
Data related to the respiratory system
Data related to follow-up care
Data related to the treatment for the cold
Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals.
Test-Taking Strategy: Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option.
Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Gas Exchange
HESI Concepts: Evidence-Based Practice/Evidence, Oxygenation/Gas Exchange
Ask health history questions while performing the examination and initiating emergency
measures
Collect health history information first, then perform the physical examination
Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room
Collect all information requested on the history form, including social support, strengths, and coping patterns
Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client’s immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment.
Test-Taking Strategy: Focus on the data in the question and note the words “alert and cooperative.” Noting that the client has not sustained life-threatening injuries will direct you to the correct option. Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Health Care Quality
HESI Concepts: Evidence-Based Practice/Evidence, Health Policy/Systems—Health Care Quality [Show Less]