Holistic Health Assessment Exam 2 (AO3320 600 FA24)

The correct answer is: C. "Notify me right away if you have any shortness of breath."

Explanation

Unilateral edema in the right leg and ankle can be a sign of deep vein thrombosis (DVT), and if a blood clot travels from the leg to the lungs, it can lead to a pulmonary embolism (PE). One of the primary signs of a pulmonary embolism is shortness of breath. If a patient experiences this symptom, it is a medical emergency that requires immediate attention. Therefore, the most important education is to inform the patient to notify the nurse right away if they experience shortness of breath, as prompt intervention is critical in such a situation.

Why the Other Options Are Wrong:

"I will compare both of your lower legs to assess for any differences." While comparing both legs for differences in size or swelling is part of the assessment, it is not the most urgent educational priority. The nurse should emphasize recognizing signs of serious complications, such as shortness of breath, rather than focusing solely on comparing the legs, which is a routine part of the assessment.

"Blood dots are more common after surgery." This statement refers to petechiae, which are small red or purple spots that can appear on the skin after surgery due to minor blood vessel ruptures. However, this is not related to the unilateral edema and does not address the more serious risks, such as DVT or PE, that could be associated with the swelling in the leg. This statement is not urgent or directly connected to the primary concern.

"Let me know if the swelling gets worse." Although it is important to monitor for worsening swelling, this option does not prioritize the more critical symptom of shortness of breath, which could indicate a pulmonary embolism. Worsening swelling can indicate more severe edema, but it is not as urgent as recognizing and addressing the potential for a pulmonary embolism.

Summary:

The most important education the nurse should provide in this situation is to notify the nurse immediately if the patient experiences shortness of breath (Option C). This is because unilateral leg edema could be a sign of deep vein thrombosis, and if a clot travels to the lungs, it could cause a pulmonary embolism, which is a medical emergency. Other options, while related to the condition, do not address the most critical and life-threatening potential complication.

Correct Answer:

Consensual response

Explanation:

The consensual response occurs when shining a light into one eye causes the pupil of the other eye to constrict. This happens because of the way the pupillary light reflex works, where both eyes react simultaneously to light exposure. The optic nerve transmits the light stimulus to the brain, which then sends signals to both the ipsilateral and contralateral (opposite) oculomotor nerves, resulting in pupil constriction in both eyes.

Why Other Options Are Wrong:

Direct reflex

This is incorrect because the direct reflex refers to the constriction of the pupil in the same eye that is directly exposed to light. In this case, the pupil constricts in the opposite eye, so the direct reflex does not apply. The direct reflex is a normal part of the pupillary light reflex but does not explain the simultaneous constriction in the other eye when light is directed at one eye.

Accommodation

This is incorrect because accommodation refers to the process by which the pupils constrict when focusing on a near object, not when light is shined into the eye. Accommodation is a separate response that occurs when the eyes adjust for close vision, and it involves both pupil constriction and eye convergence, but it is not related to the light reflex.

Convergent response

This is incorrect because the convergent response involves both eyes moving inward to focus on a near object, a motor function that is unrelated to pupil constriction in response to light. It is a separate mechanism driven by the extraocular muscles and does not occur when light is shined into the eye. The convergent response focuses on eye alignment rather than pupil reaction.

Correct Answer:

"Before I get ready to examine the painful area, I will let you know in plenty of time."

Explanation:

This response reflects therapeutic communication and patient-centered care. By informing the patient in advance before examining a painful area, the nurse helps the patient mentally prepare for the discomfort, which can ease anxiety and promote a sense of control. This approach builds trust and demonstrates respect for the patient’s experience. It also aligns with best practices in trauma-informed and empathetic care, where transparency and patient consent are prioritized during physical assessments.

Why Other Options Are Wrong:

"You don't need to worry about anything. I will make sure to be very gentle during the exam."

This response is problematic because it may unintentionally minimize the patient’s anxiety and concerns. Telling someone “you don’t need to worry” can come across as dismissive, especially to a person who is already in pain. While the intention to be gentle is good, the phrasing does not adequately acknowledge the patient’s emotional state or provide them with control over the situation. Empathetic communication should validate concerns rather than brush them aside.

"Since you're having pain in a certain area, I won't have to do a very detailed exam there."

This is incorrect because it implies the nurse will avoid a thorough assessment due to the patient’s discomfort. While sensitivity to pain is important, skipping a comprehensive exam could result in missed clinical findings or an incorrect diagnosis. The nurse’s role includes assessing all relevant areas, including painful ones, with appropriate caution and communication. Avoiding the exam undermines the quality of care and may compromise patient safety.

"I'm going to examine the area where you're having pain first to get a better picture of what's going on."

Although this might seem efficient, starting the exam in the painful area could heighten the patient’s stress and discomfort. It’s generally better to begin with less sensitive areas to help the patient acclimate to the exam process and build trust. Starting with the most painful part could lead to guarding behaviors or heightened anxiety, which can interfere with the assessment and patient cooperation. A gradual approach, as offered in the correct answer, is more effective for both comfort and clinical accuracy.

The correct answer is: D. "This information will help us to identify concerns and needed interventions to better care for you."

Explanation 

This response is the best because it acknowledges the client's feelings and provides a clear, rational explanation of why the nurse is assessing the client’s spirituality. Understanding a client’s spiritual needs, beliefs, and values is important in providing holistic care. Spirituality can be a significant factor in coping with illness, surgery, and the healthcare experience, so knowing about it can help the healthcare team provide care that is respectful and supportive of the client's individual needs. This response helps validate the client’s concerns without dismissing or minimizing them, while also providing the nurse’s professional rationale.

 Why the Other Options Are Wrong:

"I understand that this is scary but I believe that God will support you and heal your tumor.": While this response shows empathy and offers emotional support, it is not the best approach because it assumes the client shares the nurse's beliefs and may overstep boundaries. The client has not expressed any specific beliefs, so the nurse should avoid making assumptions about spirituality. The goal should be to ask the client how their spirituality influences their healthcare decisions, rather than imposing personal beliefs.

"It sounds like you are frustrated by my questions. We do not need to review this information.": This response is dismissive and does not address the client’s spiritual needs. It also fails to explain the importance of assessing spirituality in healthcare. Simply opting to stop the assessment does not allow the nurse to gather important information that could help improve care or address potential concerns the client may have, especially in relation to the surgery or emotional support.

 "We need to make plans in case there are unexpected outcomes of your surgery.": This response may be appropriate in some contexts, but it does not directly address the client’s concerns about the spirituality assessment. While planning for potential outcomes is an important part of preoperative care, the response does not explain why spirituality is part of the nurse’s holistic approach or offer an opportunity for dialogue about the client's spiritual needs.

Summary:

The most appropriate response is D, as it explains the nurse’s intent to provide holistic care that addresses the client’s physical, emotional, and spiritual needs. This approach is respectful, informative, and opens the door for further discussion, while also acknowledging the client’s feelings of frustration. The other responses either assume beliefs, dismiss the conversation, or focus on outcomes unrelated to the client’s concern about the assessment.

Correct Answer A: How can I modify this patient's environment to facilitate his or her adaptation?

Detailed Explanation of the Correct Answer:

A. This statement best reflects Callista Roy's Adaptation Model of Nursing, which is based on the idea that humans are adaptive systems who respond to environmental stimuli. The nurse’s role, according to Roy, is to assess the patient’s adaptive responses and then intervene to help the patient positively adapt to health challenges. Modifying the environment to promote adaptation is a core strategy in Roy's model, aiming to support the patient's physiologic, self-concept, role function, and interdependence needs.

Why the Other Options Are Incorrect:

B. This reflects Madeleine Leininger’s Transcultural Nursing Theory, which focuses on providing culturally congruent care.

C. This statement aligns with Dorothea Orem’s Self-Care Deficit Theory, which centers on identifying and addressing patients’ inability to care for themselves.

D. This describes Hildegard Peplau’s Interpersonal Relations Theory, which emphasizes the nurse–patient relationship and how it facilitates understanding and behavior change.

Summary:

The idea of modifying the environment to support a patient's ability to adapt is central to Callista Roy's theory, making the correct answer A. "How can I modify this patient's environment to facilitate his or her adaptation?".

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:

The client has recently begun a new medication.

Explanation:

Delirium is an acute confusional state characterized by sudden cognitive changes, which can be triggered by various factors, including medications. A recent change in medication is a common precipitating factor for delirium, particularly in older adults. Certain medications, especially those with sedative or anticholinergic properties, can alter the brain’s function and lead to delirium. This is especially true for drugs like benzodiazepines, opioids, or certain antihistamines. Since the onset of delirium is usually rapid and fluctuating, a new medication is a likely cause and should be thoroughly investigated.

Why the Other Options Are Wrong:

The client has a family history of cognitive disorders.

This is incorrect because a family history of cognitive disorders, such as dementia, is more indicative of a chronic cognitive condition, not delirium. Delirium is an acute condition that develops suddenly, whereas dementia is a slow, progressive decline in cognitive function. The gradual onset of cognitive changes in conditions like Alzheimer’s disease differs from the rapid, fluctuating nature of delirium.

The client has a history of hypertension.

This is incorrect because although hypertension can contribute to long-term cognitive decline and increase the risk of vascular dementia, it is not typically a direct cause of delirium. Delirium is usually triggered by acute factors, such as infections, medications, or environmental changes, rather than chronic conditions like hypertension. Chronic conditions can exacerbate cognitive impairment but are not the primary cause of delirium.

The client's cognition has declined over a period of several months to a year.

This is incorrect because a gradual decline in cognition over several months to a year is characteristic of dementia, not delirium. Dementia involves a slow, progressive decline in memory, reasoning, and other cognitive functions, whereas delirium has a sudden onset with fluctuating symptoms. Delirium often occurs rapidly, within hours or days, and can improve with proper treatment of the underlying cause.

Correct Answer A: Orem

Detailed Explanation of the Correct Answer:

A. Dorothea Orem is correct because she is the nursing theorist who developed the Self-Care Deficit Nursing Theory. Her theory is based on the belief that people want to take care of themselves and maintain control over their own health and lives. When individuals are unable to meet their own self-care needs due to illness, injury, or limitations, a self-care deficit occurs, and nursing intervention becomes necessary.

Orem’s theory includes three related concepts:

Self-Care – Activities individuals initiate and perform on their own behalf.

Self-Care Deficit – When individuals are unable to care for themselves.

Nursing Systems – How nurses help meet the self-care needs of patients (wholly compensatory, partially compensatory, or supportive-educative).

Why the Other Options Are Incorrect:

B. King – Imogene King is known for the Theory of Goal Attainment, which emphasizes nurse–patient communication and mutual goal setting.

C. Watson – Jean Watson developed the Theory of Human Caring, focusing on the nurse–patient relationship, empathy, and holistic care.

D. Peplau – Hildegard Peplau is recognized for her Interpersonal Relations Theory, which centers on the therapeutic relationship between nurse and patient, especially in psychiatric nursing.

Summary:

The theorist best known for focusing on self-care and self-care deficit with the idea that people want to manage their own lives is Dorothea Orem. The correct answer is A. Orem.

Correct Answer A: Florence Nightingale

Detailed Explanation of the Correct Answer:

A. Florence Nightingale is correct because she emphasized the importance of the environment in healing and health. According to her Environmental Theory, factors such as clean air, light (especially sunlight), proper nutrition, cleanliness, and quiet were essential components of effective patient care. Nightingale believed that a healthy environment could help the body heal itself.

In this scenario, the nurse is intentionally adjusting the lighting and nutrition, aligning directly with Nightingale’s principles that the nurse’s role includes modifying the environment to support the patient’s recovery.

Explanation of Why the Other Options Are Incorrect:

B. Jean Watson – Known for her Theory of Human Caring, which focuses on emotional connection, compassion, and holistic care through a transpersonal relationship between nurse and patient. The scenario focuses more on environmental and physical factors, not Watson's primary emphasis.

C. Callista Roy – Developed the Roy Adaptation Model, which focuses on how patients adapt to changes in health and environment through coping mechanisms. While environment matters in her theory, the nurse's actions here align more closely with Nightingale’s direct environmental focus.

D. Imogene King – Known for the Theory of Goal Attainment, which emphasizes communication, mutual goals, and personal interactions between nurse and patient. This scenario doesn’t reflect goal-setting or interaction, but rather environmental adjustments.

Summary:

By adjusting sunlight exposure and ensuring proper diet, the nurse is applying Florence Nightingale’s Environmental Theory, which highlights how environmental factors contribute to healing. The correct answer is A. Florence Nightingale.