Appendix A Answers to review questions

CHAPTER 1: THE CONTEXT OF HEALTH ASSESSMENT

1. a

2. d

3. b

4. iv

5. c

6. d

CHAPTER 2: CRITICAL THINKING IN HEALTH ASSESSMENT

1. c

2. b

3. c

4. 4

5.

a. True
b. False: Always eliminate any extraneous variables that could influence results
c. True
d. False: find the missing pieces, as identifying missing information is an essential critical thinking skill

CHAPTER 3: DEVELOPMENTAL TASKS AND HEALTH PROMOTION ACROSS THE LIFE CYCLE

1. c

2. b

3. a

4. d

5. c

6. d

7.

a. T,
b. F, Self-esteem becomes the way we value our own competence. It may affect the way we behave in the future
c. T,
d. T,
e. F, pre-schoolers bones are developing so they need highly nutritious food
f. F – Middle school children further develop self-esteem, adolescents search for identity

8. d

9. c

10. a

11. c

12. b

CHAPTER 4: CULTURAL COMPETENCE: CULTURAL CARE

1. c

2. b

3.

a. False
b. True
c. False
d. True
e. True

4. d

5. a

6. c

7. e

8.

a. True
b. False
c. True
d. True

9.

a. True
b. False – focus is on the past
c. True – often request the latest equipment
d. False – Nurses focus on the present – NOW

10. A-2

B-3

C-1

11. d

CHAPTER 5: DOMESTIC VIOLENCE

1. d

2. a

3. b

4. e

5. e

6. c

7. b

8.

a. False – Nurses who suspect child abuse or neglect should involve other members of the healthcare team (medical practitioners, social workers, counsellors) as screening and assessing processes are complex and there are serious implications for the child and their family.
b. True
c. True
d. False – You must determine the developmental level to ensure that the injuries sustained are not related to “normal” developmental progression
e. True
f. True

9. d

10. e

CHAPTER 6: THE INTERVIEW

1. a

2. a

3. b

4. c

5. d

6. b

7. a

8. d

9. b

10. d

11. b

12. c

13. a

14. b

CHAPTER 7: THE COMPLETE HEALTH HISTORY

1. d

2. a

3. b

4. c

5. c

6. a

7. d

8. b

CHAPTER 8: PHYSICAL ASSESSMENT TECHNIQUES

1. Concerning physical assessment

a. True: it begins with the general survey
b. True
c. False: natural light is the best but if not available use 2 light sources to minimize shadowing
d. False: to continue if the patient complains of pain may cause further damage to the area
e. False: it is the least utilised palpation technique for nurses.
f. True
g. False: the quality of the percussion is affected by the thickness of the body wall
h. False: it excludes external or environmental sounds
i. True

2. d

3. c

4. b

5. a

6. d

7. c

8. a

9. b

10. c

CHAPTER 9: GENERAL SURVEY, MEASUREMENT, AND VITAL SIGNS

1. d

2. c

3. b

4. c

5. a

6. b

7. a

8. b – only count for 60 seconds if pulse is irregular, 30 seconds and multiply by 2 is accurate if the pulse is regular

9. b

10. d

11. a

12. d

13. c

14. True or false

a. False: Temperature is not a reliable index of the older person’s true health state. Sweat gland activity is diminished.
b. True
c. False: Respirations. Ageing causes a decrease in vital capacity and a decreased inspiratory reserve volume
d. True

CHAPTER 10: PAIN ASSESSMENT: THE FIFTH VITAL SIGN

1. c

2. b

3. c

4. d

5. d

6. b and c are both correct, and would depend on the child.

7. b False: According to the American Pain Society (1992: 3): In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions, (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. In fact, a comfortable patient is better able to cooperate with diagnostic procedures.

8. d

9. c

10. d

11. b is correct.

• a – incorrect. Self-assessment pain scales can be used reliably in most patients with mild-to-moderate cognitive impairment although dementia and delirium can limit a person’s ability to report pain
• b- correct
• c – incorrect. Observation is VERY important
• d – incorrect. Behaviours such as restlessness, frowning and grimacing or sounds such as grunting or groaning can be used to assess pain but may not always be valid indicators of pain in non-verbal adults

12. Match:

a. Neonatal post surgery use 3. CRIES
b. 2-year-old child with broken arm use 1. Baker-Wong Scale
c. Middle-aged man following melanoma removal use 4. Numeric rating scale
d. Aged person with cognitive decline use 2. Abbey pain scale

CHAPTER 11: PERIPHERAL VASCULAR SYSTEM AND LYMPHATIC SYSTEM

1. a

2. c

3. c

4. a

5. c

6. d

7. a

8. d

9. b

10. d

11. a

12. c

13. a

14. c

CHAPTER 12: HEART AND NECK VESSELS

1. c

2. b

3. c

4. b

5. d

6. d

7. b

8. b

9. a

10. a

11. a

12. b

13. c

14. c

15. Match Column A with Column B

1. e
2. c
3. f
4. a
5. b
6. d

16. Liver to right atrium via inferior vena cava, head and neck to right atrium via superior vena cava, through tricuspid valve to right ventricle, through the pulmonic valve to the pulmonary artery, is oxygenated in the lungs, returns to left atrium, to left ventricle via mitral valve, through aortic valve to aorta, and out to the body.

17. The major modifiable risk factors for heart disease and stroke are high blood pressure, smoking, high cholesterol levels, obesity, physical inactivity, and diabetes. Family history of heart disease, age and for some women, the use of oral contraceptives and postmenopausal hormones are other risk factors.

18. True and False questions

a. True. This is due to stiffening of the large arteries, which, in turn is due to calcification of vessel walls (arteriosclerosis). This f. stiffening creates an increase in pulse wave velocity because the less compliant arteries cannot store the volume ejected.
b. False. The overall size of the heart does not increase with age, but left ventricular wall thickness increases. This is an adaptive mechanism to accommodate the vascular stiffening mentioned earlier that creates an increased workload on the heart.
c. False. There is no change in resting heart rate with ageing.
d. True. Cardiac output at rest does not change with ageing.
e. True. There is a decreased ability of the heart to augment cardiac output with exercise as shown by a decreased maximum heart rate with exercise and diminished sympathetic response. Noncardiac factors also cause a decrease in maximum work performance with ageing: decrease in skeletal muscle performance, increase in muscle fatigue, increased sense of dyspnoea.
f. False. Supraventricular and ventricular arrhythmias increase with age as do ectopic beats and these are usually asymptomatic in healthy older people, but they may compromise cardiac output and blood pressure when disease is present.
g. True. Age-related changes in the ECG occur as a result of histological changes in the conduction system. These include a Prolonged P-R interval (first-degree AV block) and prolonged Q-T interval, but the QRS interval is unchanged. Left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch and an increased incidence of bundle branch block.

CHAPTER 13: NOSE, MOUTH, AND THROAT

1. c

2. d

3. a

4. a

5. b

6. b

7.

a. = 3
b. = 1

c. = 2

circumoral pallor occurs with shock and anemia; cyanosis with hypoxaemia and chilling; cherry red lips with carbon monoxide poisoning,

8. d

9. c

10. a

11. d

12. a

13. b With pleural adhesions the trachea is pulled towards the affected (diseased) side

14. Lymph nodes

1. c
2. e
3. f
4. h
5. g
6. i
7. j
8. b
9. d
10. a

CHAPTER 14: THORAX AND LUNGS

1. a

2. b

3. b

4. a

5. c

6. b

7. b

8. d

9.

a. 4
b. 3
c. 2
d. 5
e. 1

10. d

11. b

12. a

13.

a. 5
b. 1
c. 3
d. 4
e. 2

14. a

15.

a. 5
b. 1
c. 4
d. 6
e. 3
f. 2

CHAPTER 15: MUSCULOSKELETAL SYSTEM

1. d

2. b

3. d

4. c

5. d

6. a

7. a

8. c

9. b (it could also be argued that d is correct, but most 2 year olds will have a pronounced lumbar lorosis which is normal)

10. d

11. c

12. b

13. True/False

a. True
b. False: Chronic pain is often associated with degenerative musculoskeletal disorders.
c. True
d. False: Rheumatoid Arthritis pain is worse in morning when arising; Osteoarthritis is worse later in the day
e. True
f. True

14. Match

1. b
2. e
3. g
4. i
5. d
6. a
7. j
8. m
9. k
10. n
11. l
12. h
13. f
14. c

CHAPTER 16: NUTRITIONAL ASSESSMENT

1. c

2. d

3. c

4. c

5. b

6. b

7. a

8. b

9. c

10. c

11. d

12. b

13. d

14. c

15. b

16. b

17. c

18. d

CHAPTER 17: SKIN, HAIR, AND NAILS

1. b

2. d

3. a

4. d

5. b

6. d

7. c

8. c

9. a

10. d

11. d

12. c

13. c

14. c

15. Physiological Jaundice

a. True
b. False: an increase
c. True
d. False: it is
e. True

16. Skin layers

1. a
2. c
3. b
4. c
5. a
6. a
7. b

17. Colour change

1. c
2. a
3. b
4. d

18. Skin Colour Change

1. b
2. a
3. g
4. c
5. f
6. d
7. e

CHAPTER 18: URINARY FUNCTION

1. True/False

1. True
2. False: the decrease in function puts the older person more at risk for health problems with rapid changes to blood volume or other insults.
3. True
4. False: the prostrate gland increases in size leading to obstruction of urine flow.

2. c

3. d

4. c

5. Match

1. b
2. d
3. a
4. c
6. b
7. a
8. d
9. c
10. c
11. A is incorrect as Prostate cancer is the most common cancer that occurs in men and the second leading cause of cancer deaths in men

CHAPTER 19: ABDOMEN

1. c

2. c

3. a

4. d

5. c

6. a

7. d

8. d

9. d

10. d

11. a

12. d

13. a

14. c

15. b

16. referred pain

1. and c
2. and e
3. and g
4. and f
5. and b
6. and i
7. and h
8. and a
9. and d

CHAPTER 20: BOWEL FUNCTION

1. a

2. c

3. a

4. b

5. a

6. d

7. b

8. False: Confirm a patent rectum and anus by noting the first meconium stool passed within 24 to 48 hours of birth. If imperforate anus there will be no passing of the meconium

9. True

10. False, they are due to an increased portal venous pressure

CHAPTER 21: MENTAL STATUS ASSESSMENT

1. d

2. a

3. d

4. c

5. b

6. d

7. c

8. b

9. c

10. True/False

a. True
b. True
c. False: sensory impairments such as vision loss may result in apathy, social isolation and depression.
d. False: Recent memory, which requires some processing (e.g. medication instructions, 24-hour diet recall, names of new acquaintances), is somewhat decreased with ageing. Remote memory is not affected

11. a

12. Match

i. c
ii. i
iii. d
iv. b
v. g
vi. f
vii. a
viii. e
ix. h

13. d

14. b

15. Patient is dressed and groomed appropriately for season and setting. Posture is erect, with no involuntary body movements. Oriented to time, person, and place. Recent and remote memory intact. Affect and verbal responses appropriate. Perceptions and thought processes logical and coherent.

CHAPTER 22: NEUROLOGIC SYSTEM

1. a

2. d

3. c

4. c

5. b

6. b

7. c

8. b

9. a

10. b

11. b

12. c

13. f

14. b

15. g

16. k

17. h

18. c

19. l

20. d

21. i

22. e

23. j

24. a

CHAPTER 23: EYES

1. b

2. c

3. a

4. b

5. d

6. b

7. a

8. c

9. a

10. c

11. a

12. c

13. b

14. b

15. b

16. d

17. a

18. Leading the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement

• Ask the person to hold the head steady and to follow the movement of your finger, pen or penlight only with the eyes.
• Hold the target back about 30 cm so the person can focus on it comfortably, and move it to each of the six positions, hold it momentarily, then back to centre.
• Progress clockwise through the positions of 2, 3, 4, 8, 9, and 10 o’clock and back to centre.
• A normal response is parallel tracking of the object with both eyes.

CHAPTER 24: EARS

1. c

2. a

3. b

4. d

5. b

6. a

7. c

8. c

9. d

10. b

11. d

12. b

13. a

14. b

15. b

16. a

17. d

CHAPTER 25: FEMALE SEXUAL AND REPRODUCTIVE FUNCTION

1. d

2. a

3. d

4. c

5. c

6. d

7. d

8. b

9. b

10. a

11. c

12. b

CHAPTER 26: MALE GENITALIA

1. c

2. c

3. c

4. d

5. d

6. c

7. d

8. b

9. a

10. d

11. a

12. a

13. b

14. e

CHAPTER 27: BREASTS AND REGIONAL LYMPHATICS

1. d

2. b

3. a

4. c

5. b

6. c

7. c

8. c

9. b

10. d

11. c

12. b

13. d

14. a

15. b

CHAPTER 28: THE PREGNANT FEMALE

1. c

2. a

3. c

4. a

5. c

6. c

7. b

8. e

9. f

10. f

11. b

12. c

13. d

14. f