D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e Chapter 1 Question 1 Type: MCSA While conducting a health history, a client states, “I am healthy, I don‟t know why I have to be here to get a check-up.” However, the client reports, type 2 diabetes mellitus and an unhealed ulcer on the left foot. Based on this information, which statement by the nurse is the most appropriate? 1. “I feel that you are in denial about your health status.” 2. “Tell me about your definition of being healthy.” 3. “Do you understand what diabetes is?” 4. “Is there anything else you are not telling me?” 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 type 2 diabetes 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 type 2 diabetes 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: 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: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Identify the key components of health assessment in nursing. MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history interview of a client. Page Number: p. 3
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TEST BANK: HEALTH AND PHYSICAL ASSESSMENT IN NURSING, 3RD EDITION, BY DAMICO, HEALTH AND PHYSICAL ASSESSMENT IN NURSING, NURSING, NURSINGTEST BANK
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