D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/eChapter 5
Question 1
Type: MCSA
The nurse is caring for a woman in the emergency room who is complaining of chest pain. She states that she was walking from her apartment to the grocery store when the pain became very severe. She reported that people were following her. She said she couldn’t really see them but she could hear them talking about “grabbing me.” While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. The nurse would obtain what further assessment data in this situation?
1. Spiritual affiliations
2. Dietary preferences and habits
3. Review of systems
4. Focused psychosocial interview
Correct Answer: 4
Rationale 1: A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited.
Rationale 2: A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited.
Rationale 3: The physical examination is conducted after the interviewing is complete.
Rationale 4: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted.
Global Rationale: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. The physical examination is conducted after the interviewing is complete.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.
Question 2
Type: MCSA
The nurse is interviewing a client prior to a physical examination. The client tells the nurse that she has been experiencing a lot of aches, pains, and abdominal discomfort. The nurse may suspect which of the following factors that impact physical health?
1. Income
2. Stress
3. Ethnicity
4. Occupation
Correct Answer: 2
Rationale 1: Income may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.
Rationale 2: Stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”
Rationale 3: Ethnicity may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.
Rationale 4: Occupation may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.
Global Rationale: All of the above factors may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5.3: Identify factors affecting psychosocial health.
Question 3
Type: MCSA
The nurse is interviewing an overweight teenager who looks downward and speaks softly when answering questions. The nurse identifies a problem with client’s self-concept. Which of the following findings would support the nurse’s conclusions?
1. Increased desire to form lasting relationships
2. Decreased ability to form attachments with other people
3. Inability to maintain stable employment
4. Feelings of worthlessness, anxiety, and/or depression
Correct Answer: 4
Rationale 1: The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.
Rationale 2: Decreased ability to form attachments to other people results from many factors not limited to poor self-concept.
Rationale 3: Decreased ability to maintain stable employment results from many factors not limited to poor self-concept.
Rationale 4: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues.
Global Rationale: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Decreased ability to maintain stable employment and to form attachments to other people results from many factors not limited to poor self-concept. The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.
Cognitive Level: Remembering
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5.1: Describe psychosocial functioning.
Question 4
Type: MCSA
A 7-year-old client was just admitted to the hospital following an appointment in the pediatric oncology clinic. His mother, who is distraught over his recent leukemic relapse, accompanies the child. She is crying and asking, “What did I do wrong? ... Why does he deserve this? ... Why can’t it be me?” The nurse understands that these statements indicate which of the following?
1. Ineffective coping
2. Emotional emptiness
3. Spiritual distress
4. Psychologic anxiety
Correct Answer: 3
Rationale 1: Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping.
Rationale 2: Emotional emptiness is not an acceptable term to describe behaviors indicating distress.
Rationale 3: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress.
Rationale 4: Further evidence would be required before determining psychologic anxiety.
Global Rationale: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress. Further evidence would be required before determining psychologic anxiety. Emotional emptiness is not an acceptable term to describe behaviors indicating distress. Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 5.3: Identify factors affecting psychosocial health.
Question 5
Type: MCSA
The nurse has gathered assessment data on a client admitted for suicidal tendencies. The nurse develops appropriate nursing diagnoses and formulates goals to achieve client outcomes. The nurse is utilizing which step of the nursing process?
1. Implementation
2. Evaluation
3. Planning
4. Assessment
Correct Answer: 3
Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal.
Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented.
Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place.
Rationale 4: Assessment is the process by which data are collected.
Global Rationale: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Assessment is the process by which data are collected.
Cognitive Level: Remembering
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.
Question 6
Type: MCSA
The nurse is assessing a client in an outpatient mental health setting. The assessment tool outlines criteria for psychosocial health. The nurse understands that this term may be defined as which of the following?
1. The state of being emotionally balanced and socially astute.
2. Being mentally stable, physically fit, and psychologically well.
3. Becoming spiritually and psychologically mature.
4. The state of being mentally, emotionally, socially, and spiritually well.
Correct Answer: 4
Rationale 1: Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness.
Rationale 2: Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health
Rationale 3: Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health.
Rationale 4: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well.
Global Rationale: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well. Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health. Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health. The same is true with being emotionally balanced and socially astute. Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness.
Cognitive Level: Remembering
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.
Question 7
Type: MCSA
The nurse is conducting a class on health promotion and uses the following definition: “The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.” The nurse is stressing which of the following areas?
1. Physical fitness
2. Emotional health
3. Physical health
4. Psychologic well-being
Correct Answer: 1
Rationale 1: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.
Rationale 2: Physical fitness is an important component of physical and emotional health.
Rationale 3: Physical fitness is an important component of physical and emotional health.
Rationale 4: Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness.
Global Rationale: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands. Physical fitness is an important component of physical and emotional health. Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5.1: Describe psychosocial functioning.
Question 8
Type: MCSA
The nurse is caring for a client admitted for severe weight loss and depression. The client has recently experienced the loss of three close family members and has withdrawn from all social activities. In developing the plan of care, the nurse would correctly choose which of the following nursing diagnoses?
1. Powerlessness
2. Anxiety
3. Dysfunctional grieving
4. Spiritual distress
Correct Answer: 3
Rationale 1: Powerlessness refers to feelings of a loss of control with the situation.
Rationale 2: Anxiety infers feelings of apprehension.
Rationale 3: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance.
Rationale 4: Spiritual distress infers the client would be at odds with her feelings.
Global Rationale: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance. There are not enough data to support the remaining nursing diagnoses. Powerlessness refers to feelings of a loss of control with the situation. Anxiety infers feelings of apprehension. Spiritual distress infers the client would be at odds with her feelings.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.
Question 9
Type: MCSA
The nurse is reviewing the plan of care for a client and notes that the following goal has not been met: “Client will verbalize three positive things about himself.” The nurse would correctly choose to do which of the following?
1. Tell the client three things that he does well.
2. Ask other clients to tell the client what he does well.
3. Determine barriers to achieving the goal.
4. Do nothing as long as the client appears better.
Correct Answer: 3
Rationale 1: Telling the client things that he does well will not aid in the achievement of the goal.
Rationale 2: Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate.
Rationale 3: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement.
Rationale 4: Ignoring the absence of progression toward the established goal will not aid the client in improving.
Global Rationale: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement. The goal statements are based upon the client’s achievements. Telling the client things that he does well will not aid in the achievement of the goal. Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate. Ignoring the absence of progression toward the established goal will not aid the client in improving.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.
Question 10
Type: MCMA
A client is admitted to the orthopedic unit after breaking an arm after a fall. The client appears disheveled and has a body odor. The family arrives and expresses surprise at the client’s appearance. They report that this is not the normal appearance of the client and that they are usually clean and meticulously groomed. Which of the following assessments does the nurse need to complete in order to formulate relevant nursing diagnoses and a plan of care for this patient?
Standard Text: Select all that apply.
1. Food preferences
2. Psychosocial assessment
3. Memory assessment and orientation
4. Family medical history
5. Body systems examination
Correct Answer: 2,3,4,5
Rationale 1: Food preferences. Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors.
Rationale 2: Psychosocial assessment. The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated.
Rationale 3: Memory assessment and orientation. The client’s appearance indicates there has been some change in mental outlook or condition. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted.
Rationale 4: Family medical history. The client’s presentation is indicative of a problem. Some disorders may be genetic, thus requiring investigation.
Rationale 5: Body systems examination. The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior.
Global Rationale: Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors. The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted. Some disorders may be genetic, thus requiring investigation. The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior.