Holistic Health Assessment Exam 2 (AO3320 600 FA24)

The first step the nurse should take when preparing to obtain information about a client's mental and psychosocial status is: B. Explain the purpose of the exam and types of questions.

Explanation:

It is crucial to explain the purpose of the assessment and the types of questions that will be asked to the client. This helps establish trust, reduce anxiety, and prepare the client for the mental health assessment. When a client understands why certain questions are being asked, they are more likely to provide accurate and open responses, which improves the quality of the information gathered.

Why The Other Options Are Incorrect

A. Question the client about their usual lifestyle and behaviors

While it's important to understand the client's usual lifestyle and behaviors, it is not the first step. You need to explain the purpose and the nature of the assessment before diving into specific questions about the client's behavior or lifestyle.

C. Perform a neurologic examination to determine any deficits:

A neurologic examination might be necessary if there are concerns about neurological issues, but it is not the first step when assessing mental and psychosocial status. Psychosocial assessments typically focus more on the mental and emotional state, so the first step is explaining the purpose of the exam.

D. Check the client's level of consciousness for changes:

Checking the level of consciousness is essential in any general assessment of mental status, but it should be done after explaining the purpose of the exam and obtaining the necessary consent or understanding from the client. It is part of the process, but not the first step in this context.

Summary:

The first step in preparing for a mental and psychosocial assessment is to explain the purpose of the exam and the types of questions that will be asked, which makes B the correct choice

The correct answer is: A. Fifth intercostal space, left midclavicular line.

Explanation

The apical impulse, also known as the point of maximal impulse (PMI), is the location where the heart's apex is closest to the chest wall. It is usually palpated in the fifth intercostal space, left midclavicular line (MCL), which corresponds to the area where the left ventricle comes into contact with the chest wall during systole (when the heart contracts). This is the most accurate location for assessing the apical impulse, and it provides information about the size, position, and function of the heart.

Why the Other Options Are Wrong:

Second intercostal space, left sternal border: This area is used for auscultating the aortic valve and the pulmonic valve, not for assessing the apical impulse. While these areas are important for evaluating heart sounds, they do not correspond to the location of the apical impulse.

Third intercostal space, left axillary line: The third intercostal space, left axillary line, is not typically used for assessing the apical impulse. This area is not aligned with the apex of the heart and would not provide the most accurate assessment of the PMI.

Fourth intercostal space, left sternal border: The fourth intercostal space, left sternal border, is used for assessing the tricuspid valve and right ventricular area, not the apical impulse. This area does not correspond to the apex of the heart and is not the correct location for palpating the PMI.

Summary:

The fifth intercostal space, left midclavicular line is the priority point for assessing the apical impulse, as this is where the left ventricle's apex comes into closest contact with the chest wall. This location provides the most accurate information about the heart's function and is essential for evaluating irregular heart rhythms and overall cardiac health. The other options correspond to different areas used to assess specific heart sounds and valves, not the apical impulse.

The correct answer is: C. Numbness.

Explanation

The Phalen test is used to assess for carpal tunnel syndrome, a condition caused by compression of the median nerve at the wrist. During the Phalen test, the patient is asked to hold their wrists in a flexed position (palms together) for about 60 seconds. A positive test is indicated by the reproduction of symptoms such as numbness, tingling, or pain in the fingers, especially the thumb, index, and middle fingers, which are innervated by the median nerve. Therefore, numbness is considered a positive response to the Phalen test, as it suggests the presence of carpal tunnel syndrome due to nerve compression.

Why the Other Options are Incorrect:

A. Hard, painless Bouchard nodes: Bouchard nodes are associated with osteoarthritis, not carpal tunnel syndrome. They are bony enlargements found on the proximal interphalangeal joints and are not a sign of nerve compression or a positive Phalen test.

B. No tingling: A negative response to the Phalen test would be no tingling or discomfort. A positive response is characterized by tingling, numbness, or pain, suggesting carpal tunnel syndrome.

D. Atrophy of the thenar prominence: Atrophy of the thenar muscles (the muscles at the base of the thumb) is a late sign of carpal tunnel syndrome, usually seen when the condition has progressed. It is not directly related to a positive Phalen test, which is focused on the immediate response of the patient when their wrists are in flexion.

Summary:

A positive response to the Phalen test is indicated by numbness or tingling in the fingers, particularly in those areas innervated by the median nerve. This response suggests carpal tunnel syndrome due to compression of the median nerve at the wrist.

Correct Answer:

Trigeminal neuralgia

Explanation:

Trigeminal neuralgia is characterized by sudden, severe, and brief episodes of facial pain that can last from a few seconds to several minutes. This pain typically follows the distribution of the trigeminal nerve (cranial nerve V), which includes the ophthalmic, maxillary, and mandibular branches. Clients often describe the pain as sharp, stabbing, or electric shock-like, and it is usually unilateral. Triggers for these painful episodes include mild stimulation such as talking, chewing, touching the face, or being exposed to wind. The absence of systemic symptoms and the presence of normal vital signs further support trigeminal neuralgia over other conditions.

Why Other Options Are Wrong:

Migraine headache

This option is incorrect because migraines are typically associated with prolonged, pulsating or throbbing headaches that last for several hours to days. They often include additional symptoms such as nausea, vomiting, photophobia, and phonophobia. Migraines tend to involve the head more than the face and are not characterized by the brief, intermittent, electric-like pain seen in trigeminal neuralgia. The client’s presentation of sudden, short-duration facial pain without systemic symptoms does not fit the classic profile of a migraine.

Temporomandibular joint dysfunction (TMJ)

TMJ dysfunction often causes dull, aching pain in the jaw or around the ear, and it is typically worsened by jaw movement such as chewing or speaking. The pain is usually persistent rather than episodic and is not described as sharp or electric in nature. TMJ issues may also be accompanied by clicking or popping sounds in the joint, which are not mentioned in the client’s report. The sudden onset and brief nature of the pain in this case are not consistent with TMJ dysfunction.

Meningitis

Meningitis is a serious infection that presents with systemic signs such as fever, headache, neck stiffness, photophobia, and sometimes altered mental status. Clients typically appear acutely ill and exhibit abnormal vital signs, including fever and increased heart rate. The client in this scenario has normal vital signs and no systemic symptoms, and the pain is localized to the face rather than generalized or involving the neck and head. These factors make meningitis an unlikely diagnosis.

The correct answer is: C) External rotation.

Rationale:

When a client is asked to bring their hands together behind their head with their elbows flexed, they are performing a movement that involves rotating the shoulders outward or away from the body’s midline. This is an example of external rotation. The shoulder joint moves in such a way that the anterior surface of the arm rotates outward.

Why The Other Options Are Incorrect

A. Abduction: Abduction refers to moving the arms away from the body’s midline, such as lifting the arms out to the sides. This is not what is happening when the arms are brought behind the head.

B. Adduction: Adduction involves bringing the arms toward the body’s midline, such as lowering the arms after performing abduction. This movement is not related to the action described.

D. Internal rotation: Internal rotation involves rotating the arms inward, as in placing the hands behind the back, which is opposite to the outward rotation needed for external rotation.

Summary:

The correct action being tested is external rotation of the shoulder joint when the client brings their hands together behind their head with elbows flexed. This movement assesses the shoulder's range of motion and the functionality of the surrounding muscles.

Correct Answer B: Metaparadigm

Detailed Explanation of the Correct Answer:

B. Metaparadigm is correct because the metaparadigm in nursing represents the broadest and most abstract level of knowledge. It defines the core concepts that are common to all nursing theories and serve as a foundation for developing frameworks and models. The four central concepts in the nursing metaparadigm are:

Person – the individual, family, or community receiving care

Environment – all external and internal factors affecting the person

Health – the level of wellness or illness

Nursing – the actions, characteristics, and responsibilities of the nurse providing care

These concepts help guide the development of more specific theories, models, and practices in the nursing discipline.

Why the Other Options Are Incorrect:

A. Philosophy – Refers to a system of beliefs and values that guide nursing practice and theory development, but it is not the most abstract structural level. It’s more about personal or institutional values.

C. Conceptual model – Provides a structured way to organize and apply the concepts of the metaparadigm, but it is less abstract and more specific than the metaparadigm itself.

D. Theory – Nursing theories explain relationships between concepts and guide practice and research, but they are more concrete and specific than a metaparadigm.

Summary:

The metaparadigm is the most abstract and foundational level of nursing knowledge, encompassing the core concepts of person, environment, health, and nursing. The correct answer is B. Metaparadigm.

Correct Answer:

The jugular venous pulse is not visible when the client is sitting upright.

Explanation:

In a healthy client, the jugular venous pulse (JVP) is typically not visible when the client is sitting upright. The jugular veins are located in the neck, and they become more visible when there is increased venous pressure, particularly in a reclining or semi-reclined position (around 30 to 45 degrees). This is because gravity plays less of a role in venous return when the client is in a more horizontal position, causing the veins to become more distended. Therefore, the absence of a visible JVP when sitting upright is considered a normal finding.

Why Other Options Are Wrong:

The jugular venous pulse is visible when the client lies supine.

This is a normal finding. When the client is lying flat (supine), gravity no longer influences venous return, allowing the jugular veins to become more distended and visible. The JVP becomes more evident because of the increased venous pressure in the neck and head. This is a typical physiological response and is often used to assess the client’s cardiovascular health.

The jugular veins are distended when the client sits at a 45-degree angle.

This is abnormal. While slight visibility of the jugular veins at a 45-degree angle is normal, distention at this angle is concerning and may indicate elevated venous pressure. Distention at this position could suggest heart failure, fluid overload, or other cardiovascular issues. A thorough assessment is needed if this finding occurs.

The jugular veins are fully distended when the client is in a high Fowler position.

This is also abnormal. The high Fowler position (sitting at about a 90-degree angle) should reduce venous pressure and not cause the jugular veins to become distended. Full distention in this position is indicative of potential right-sided heart failure or elevated central venous pressure (CVP). This would require further investigation to determine the underlying cause.

Correct Answer:

Clear, watery drainage from the ear.

Explanation:

Clear, watery drainage from the ear is a potential medical emergency, particularly if it occurs after a head injury. This type of drainage could be cerebrospinal fluid (CSF) leaking from the ear, a condition that can arise from basilar skull fractures. CSF leakage is a serious complication because it may lead to infection, such as meningitis, and indicates that the protective barriers around the brain and spinal cord have been compromised. Immediate medical attention is required to evaluate the cause, manage the leakage, and prevent further complications, making this a high-priority finding in any clinical setting.

Why Other Options Are Wrong:

Odorless, brown cerumen in the ear.

This is incorrect because brown cerumen (earwax) is a normal, natural substance produced by the ear to help protect the ear canal from dirt and bacteria. It is not a cause for concern unless accompanied by symptoms such as pain, hearing loss, or infection. Therefore, odorless, brown cerumen does not require urgent medical attention and does not indicate an emergency.

Enlarged post-auricular lymph nodes.

This is incorrect because enlarged lymph nodes behind the ear (post-auricular) are often a sign of infection or inflammation, but they do not typically represent an immediate emergency. Enlarged lymph nodes could be related to ear infections, upper respiratory infections, or other benign conditions. While further evaluation may be needed to determine the cause, enlarged lymph nodes alone do not suggest a life-threatening situation, unlike CSF leakage.

White spots on the tympanic membrane.

This is incorrect because white spots on the eardrum (tympanic membrane) are usually signs of past infections or scarring. They do not indicate an acute or life-threatening condition. While they may suggest a history of ear infections or other issues, they do not require immediate attention unless other alarming symptoms are present, such as pain or hearing loss. Therefore, this is not an emergency situation compared to CSF leakage from the ear.

Correct Answer:

Deviation of the heel to one side.

Explanation:

This test is designed to assess motor coordination, specifically evaluating cerebellar function. The cerebellum is responsible for the coordination of voluntary movements, balance, and fine motor control. When a client is asked to slide the heel of one foot down the shin of the opposite leg, it requires precise and coordinated movement. If the client’s heel deviates to one side, it indicates that the cerebellum is not coordinating the movement properly. This is a sign of cerebellar dysfunction and may suggest ataxia, a condition in which the coordination of movement is impaired due to cerebellar damage or dysfunction.

Why Other Options Are Wrong:

Pain and flexion in the knee.

Pain and flexion in the knee during this test could indicate discomfort or muscle tightness, but it does not suggest cerebellar dysfunction. Cerebellar coordination issues would be reflected in the smoothness and accuracy of the movement, not in pain. Pain is not a typical symptom of cerebellar problems, and the test specifically evaluates coordination, not pain response or muscle flexion.

Rapid oscillations of the ankle.

Rapid oscillations, or tremors, of the ankle may indicate other motor control issues, but they are not typically a primary finding during a coordination test for cerebellar function. While intention tremors (which are tremors that occur when a person is performing a task) can be associated with cerebellar dysfunction, they are usually observed when the individual is trying to reach for something or during purposeful movement. Oscillations in the ankle, while important, do not directly suggest the cerebellar dysfunction being assessed in this specific coordination test.

The client reports paresthesia.

Paresthesia (numbness or tingling) is related to sensory dysfunction, usually associated with issues in the peripheral nervous system, such as nerve impingement or neuropathy, rather than cerebellar motor control. The cerebellum is involved in motor coordination and balance, not in the sensation of touch or the transmission of sensory information. Therefore, paresthesia would not be a direct indicator of cerebellar dysfunction.