Chapter 1: The Nurse's Role in Health Assessment Multiple Choice 1. A) B) C) D)
What is one of the priority goals of nursing practice? To influence private policy To further the interests of the nursing profession To promote privacy in health care To advocate for patients and communities
Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 5, Advocacy Taxonomic Level: Knowledge Feedback: Nurses engage in many activities in the course of nursing practice. Among the most important goals of the nurse is the advocacy role of the nurse. This role supersedes the importance of promoting the profession and promoting privacy, even though both are laudable goals. Nurses normally aim to influence public, not private, policy. 2. What do nursing activities that promote health and prevent disease primarily accomplish? A) Reduce an individual's risk of illness B) Reduce recovery times C) Optimize self-care abilities D) Create home care safety Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Easy Objective: 3 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Analysis Feedback: Nursing activities that promote health and prevent illness reduce the risk of disease. These activities are not primarily focused on reducing recovery times,
optimizing self-care, or creating home safety, though each of these outcomes is congruent with the philosophy of health promotion. 3. A) B) C) D)
The purpose of a health assessment includes what? Identifying the patient's major disease process Collecting information about the health status of the patient Clarifying the patient's extended health care benefits Explaining the patient's overall health to him or her
Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Analysis Feedback: Health assessment is the collection of subjective and objective data to develop a database about a patient's health status (past and present), health concerns, and usual coping mechanisms so that an individualized care plan can be created. The patient's health care coverage is not a component of health assessment, and it is not normally the nurse's role to explain the patient's overall health or identify particular diseases. 4. The nurse is conducting a physical assessment. The data the nurse would collect vary depending primarily on what factor? A) How much time the nurse has B) The patient's acuity C) The patient's cooperation D) Onset of current symptoms Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 10, Types of Health Assessments Taxonomic Level: Comprehension Feedback: Data that nurses collect during a physical assessment vary depending on a patient's acuity, health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the patient is, or the onset of the current symptoms.
5. A nursing instructor is discussing the purposes of health assessment. What is a priority purpose of health assessment? A) To establish a database against which subsequent assessments can be measured B) To establish rapport with the patient and family C) To gather information for specialists to whom the patient might be referred D) To quantify the degree of pain a patient may be experiencing Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Analysis Feedback: Health assessment is the collection of subjective and objective data to develop a database about a patient's health status (past and present), health concerns, and usual coping mechanisms so that an individualized care plan can be created. Rapport is important but is not a priority goal of health assessment. It is not normally the nurse's role to gather data for specialists. Pain assessment is an important component of most assessments but is not a primary purpose for assessment. 6. How do nurses primarily facilitate the achievement of high-level wellness with a patient? A) By encouraging the patient to keep appointments B) By providing information on alternative treatments C) By promoting patients' health D) By providing efficient patient care Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Health and Wellness Difficulty: Easy Objective: 3 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Analysis Feedback: High-level wellness is a process by which people maintain balance and direction in the most favourable environment. The role of nurses is to facilitate this achievement through health promotion and teaching. Nurses do not necessarily facilitate the achievement of high-level wellness by encouraging patients to keep appointments, providing information on alternative treatments, or providing “efficienct” patient care.
7. The nurse is caring for a patient who, on the continuum between wellness and illness, is moving toward illness and premature death. How would the nurse know this to be true? A) The patient stops doing wellness-promoting activities. B) The patient develops signs and symptoms. C) The patient begins exercising. D) The patient verbalizes anxiety over the cost of medications. Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Evaluation Feedback: The person who moves toward illness and premature death develops signs, symptoms, and disability, which, unfortunately, is when most treatment occurs in the current health care system. The patient who stops performing wellness-promoting activities is not necessarily moving toward death. A patient who begins exercising is moving toward wellness, not illness. The verbalization of anxiety over financial matters is not an indication of illness. 8. Nurses collaborate with individuals, families, groups, and communities to implement health promotion, risk reduction, and disease prevention strategies. What is an example of primary prevention? A) Conducting a public blood glucose monitoring campaign B) Administering antibiotics to a patient with sepsis C) Providing immunizations to school children D) Screening for high blood pressure Ans: C Age Group: Child and Adolescent Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Difficult Objective: 3 Page and Header: 7, Risk Assessment and Health Promotion Taxonomic Level: Analysis Feedback: Immunizations are an example of primary prevention, while BP and diabetes screening are secondary prevention measures. Active treatment of illness is associated with tertiary prevention.
9. A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostic statements in the care plan, what would the nurse primarily use? A) Rationales B) Canadian Nurses Association recommendations C) Physical assessment skills D) Clinical reasoning Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 9, Clinical Reasoning Taxonomic Level: Analysis Feedback: Nurses use clinical reasoning and critical thinking to formulate diagnostic statements. Rationale, CNA recommendations, and physical assessment skills are not central to the process of formulating diagnostic statements, though each may be integrated into the process. 10. A nurse is caring for three patients whose care involves complex situations and multiple responsibilities. What is most important to resolving problems for this nurse? A) Intuition B) Physical assessment C) Critical thinking D) Nursing care plan Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 9, Critical Thinking Taxonomic Level: Application Feedback: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems and is more important than intuition. Care plans and physical assessments are not useful in the absence of critical thinking. 11. A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
A) Nursing process B) Diagnostic reasoning C) Critical thinking D) Community care map Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Community Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Application Feedback: The nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities. Diagnostic reasoning, critical thinking, and community care maps are integrated into nursing but are not frameworks for providing individualized care to a community. 12. Which of the following is a recognized type of nursing assessment? A) Physical B) Implied C) Mental D) Emergency Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 10, Types of Health Assessments Taxonomic Level: Knowledge Feedback: Three types of nursing assessments are common—emergency, focused, and comprehensive. 13. A nurse performs a comprehensive assessment on a patient. What is a unique component of this assessment? A) Circulatory assessment B) Assessment of the airway C) Complete health history D) Disability assessment Ans: C Age Group:
All Age Groups
Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 11, Comprehensive Assessment Taxonomic Level: Application Feedback: The comprehensive assessment includes a complete health history and physical assessment. It is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or every 8 hours for patients in intensive care. Focused assessments and emergency assessments do not include a complete health history. 14. The nurse is admitting a patient to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment? A) It covers the body from head to toe. B) It occurs only in the clinic area. C) It involves all body systems. D) It is more in-depth on specific issues. Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 11, Focused Assessment Taxonomic Level: Analysis Feedback: A focused assessment is based on the patient's issues. This type of assessment can occur in all settings, including the clinic, hospital, and home health. It usually involves one or two body systems and is smaller in scope than the comprehensive assessment but is more in-depth on the specific issue(s). 15. A nurse is admitting a patient, has completed the health history, and is now doing a physical assessment. The physical assessment will primarily provide what type of data? A) Concrete B) Subjective C) Realistic D) Objective Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual
Competency Category: Changes in Health Difficulty: Easy Objective: 6 Page and Header: 13, Components of the Health Assessment Taxonomic Level: Comprehension Feedback: The physical assessment follows the history and focused interview and includes objective data, which are measurable. Subjective data are gathered during the health history. Concrete and realistic data are distracters for this question. 16. The nurse is performing a health assessment on a new patient. While taking the detailed history, the nurse knows to include what information? A) Functional status B) Only data involving the patient complaint C) A focused assessment of the patient complaint D) Family history for the past three generations Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 13, Components of the Health Assessment Taxonomic Level: Knowledge Feedback: A detailed history includes data on all systems, psychosocial and mental health, and functional status. Family histories generally go back only to grandparents, not great-grandparents. 17. When documenting the results of a health assessment, what principle must the nurse follow? A) Documentation must be kept secure and private. B) Documentation must be freely shared with all stakeholders. C) Documentation becomes a publically accessible record after 7 years. D) Documentation should be expressed according to the nurse's preferences. Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Professional Practice Difficulty: Difficult Objective: 7 Page and Header: 14, Documentation and Communication Taxonomic Level: Synthesis Feedback: Legislation regulates the security and privacy of information that is
contained in nursing documentation. Accordingly, it does not become a publically accessible record and is not necessarily shared with all stakeholders. It should be performed in a standardized manner, not guided by the nurse's individual preferences. 18. The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the patient. The students know that this type of information is assessed in what type of assessment? A) Body systems B) Head to toe C) Functional D) Comprehensive Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 6 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Analysis Feedback: A functional assessment focuses on the patterns that all humans share—health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs. 19. A clinical instructor is teaching a group about organizing data when documenting and communicating findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment? A) Body systems B) Comprehensive C) Head to toe D) Functional Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Evaluation
Feedback: A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data. 20. A nurse is assessing a 14-year-old girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the patient is what? A) Body systems B) Functional C) Focused D) Head to toe Ans: D Age Group: Child and Adolescent Chapter: 1 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 5 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Analysis Feedback: The head-to-toe method is efficient and provides more modesty for patients than other modes of assessment.
Chapter 2: Interviewing and Therapeutic Communication Multiple Choice 1. A nursing instructor is explaining and analyzing nonverbal communication with the nursing class. The instructor explains that facial expressions should be A) humourous. B) stoic. C) relaxed. D) detached. Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 22, Nonverbal Communication Skills Taxonomic Level: Comprehension Feedback: Facial expressions should be relaxed, caring, and interested. Detached and stoic expressions are likely to hinder partnership, and humourous expressions are inappropriate in many circumstances. 2. A nurse is admitting a new patient who is currently lying in bed. Where should the nurse be positioned? A) Seated in a chair at eye level with the patient B) Sitting on the side of the bed, looking down at the patient C) Leaning on the nightstand at eye level with the patient D) Standing beside the bed, looking down at the patient Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 22, Nonverbal Communication Skills Taxonomic Level: Application Feedback: To facilitate optimal eye contact, the nurse needs to be at eye level with the patient. Those who stand while patients are in bed will be taller than patients, assuming a position of power. Thus, the nurse should be seated in a chair at eye level
with patients who are in bed during interviews. 3. In some situations, a way to apply nonverbal communication effectively is through silence. The purposeful use of silence during the interview allows patients to do what? A) Rest and improve health B) Provide accurate answers C) Compensate for decreased levels of consciousness D) Withdraw from the nurse Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 2 Page and Header: 24, Silence Taxonomic Level: Analysis Feedback: The nurse uses silence purposefully during the interview to allow patients time to gather their thoughts and provide accurate answers. He or she also uses silence therapeutically to communicate nonverbal concern. Silence also gives patients a chance to decide how much information to disclose. Silence is not intended to allow withdrawal from the therapeutic relationship. 4. A nurse is interviewing a patient who uses a verbal expression with which the nurse is unfamiliar. What is the most appropriate statement for the nurse to use to clarify the expression's meaning from the patient? A) Tell me what you mean by ________? B) I think that expression means ____________. C) That expression is unclear to me. D) Where did you hear that expression? Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 24, Clarification Taxonomic Level: Synthesis Feedback: Clarification is important when the patient's word choice or ideas are unclear. For example, the nurse states, “Tell me what you mean by _____?” Another way to clarify is to ask, “What happens when you _____?” Such questions prompt patients to identify other symptoms or give more information, so that the nurse better
understands. The nurse also can use clarification when the patient's history of illness is confusing. This is superior to guessing or asking the patient where he or she heard the expression. 5. The patient tells the nurse that he is sorry he fell off the roof and broke his leg. The nurse responds by saying, “Oh, you poor thing! I've had injuries too, so I know how you're feeling.” What type of response is this? A) Empathetic B) Therapeutic C) Sympathetic D) Supportive Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 3 Page and Header: 25, Sympathy Taxonomic Level: Analysis Feedback: Sympathy is feeling what a patient feels from the viewpoint of the nurse. When the nurse is being sympathetic, he or she is not being therapeutic, because the nurse is interpreting the situation as he or she perceives it. Because this response is nontherapeutic, it is also nonsupportive. 6. A nursing instructor is discussing therapeutic versus nontherapeutic responses with nursing students. Which of the following would the nurse identify as nontherapeutic? A) Clarification B) Using technical language C) Summarizing D) Focusing Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 3 Page and Header: 6, Technical or Overwhelming Language Taxonomic Level: Comprehension Feedback: Using technical language often contributes to nontherapeutic communication. The other given options are therapeutic responses.
7. A nurse is preparing to admit a new patient to the unit and is reviewing the patient's record chronologically. In what phase of the interview process are the nurse and the patient? A) Preinteraction B) Beginning C) Working D) Ending Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 4 Page and Header: 27, Preinteraction Phase Taxonomic Level: Analysis Feedback: In the preinteraction phase, the nurse reviews the record chronologically to detect patterns of illness, such as declining functional status, and to identify how things fit together. This precedes the other listed phases. 8. During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions? A) Preinteraction B) Beginning C) Working D) Ending Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 4 Page and Header: 28, Working Phase Taxonomic Level: Comprehension Feedback: During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended questions. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. 9. The nurse is interviewing a patient from a culture different from that of the nurse. The nurse works to preserve the code of conduct that shows respect for others. What
is this code of conduct called? A) Good manners B) Direct communication C) Nonverbal communication D) Communication etiquette Ans: D Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 28, Intercultural Communication Taxonomic Level: Comprehension Feedback: Communication etiquette refers to the code of conduct and good manners that show respect for others. Such etiquette varies between and within cultures. Options A, B, and C are incorrect. 10. A patient who only speaks Mandarin is admitted to the unit. The patient's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this patient? A) The sister may not tell the patient exactly what the nurse says. B) The patient's sister may not understand medical terminology. C) The sister may not be there every time the nurse needs to talk to the patient. D) The patient may not want her sister to know her private information. Ans: D Age Group: Adult Chapter: 2 Client Type: Family Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 30, Working with an Interpreter Taxonomic Level: Evaluation Feedback: Using children in the family, other relatives, or close friends as interpreters violates privacy laws, because patients may not want to share personal information with others. Comprehension and access are not the central problems with using family members to interpret. 11. A nurse is performing an admission assessment on a patient new to the unit. What would be the best way to phrase a question about the patient's marital status? A) “Is your spouse living with you?” B) “Are you living with your spouse?”
C) “Do you live alone or with someone?” D) “Are you married, divorced, or widowed?” Ans: C Age Group: Adult Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 30, Gender and Sexual Orientation Issues Taxonomic Level: Synthesis Feedback: An inclusive, sensitive, and ultimately better question by which to determine the patient's marital status is, “Do you live alone or with someone?” This phrasing provides a more direct avenue for finding out about support at home and better reflects diversity and inclusiveness. 12. A pediatric nurse is working in a community health clinic and seeing a 6-year-old boy. What is the most appropriate way to address this child and his parents? A) Call the child by his legal name and refer to the parents as Mr. and Mrs. B) Call the child by his first name and ask the parents how they prefer to be addressed. C) Call the child by his first name and refer to the parents as Mr. and Mrs. D) Call the child by his full name and refer to the parents as “mom” and “dad.” Ans: B Age Group: Adult Chapter: 2 Client Type: Family Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 6 Page and Header: 31, Lifespan Issues Taxonomic Level: Application Feedback: The nurse should refer to children by their first names and ask parents what name they prefer for address. He or she avoids calling parents “mom” or “dad” to maintain professional communication. 13. A clinic nurse is caring for a newborn and her parents. Observing parental behaviour is an important nursing function during this child's well-baby visit. What would the nurse expect during observation? A) Parents encouraging the baby's happy behaviours. B) Parents feeding the baby every time she appears upset or cries. C) Parents ignoring the infant's fussy behaviour. D) Parents playing with an irritable infant.
Ans: A Age Group: Infant Chapter: 2 Client Type: Family Competency Category: Health and Wellness Difficulty: Moderate Objective: 6 Page and Header: 31, Newborns and Infants Taxonomic Level: Analysis Feedback: The nurse observes parents as they speak to their infants for encouragement of happy behaviours and comfort for crying. Parental behaviour should be appropriate for the situation; a detached or irritable parent is cause for concern. The nurse would not expect to see the parent attempt to solve all problems by feeding the infant. 14. A nurse is interviewing a 76-year-old man who has come to the clinic for the first time. The nurse ensures that every question is absolutely necessary because A) older adults know which subjects are most important. B) older adults have longer health histories. C) older adults take more medications. D) older adults tire more easily. Ans: D Age Group: Older adult Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 6 Page and Header: 32, Older Adults Taxonomic Level: Comprehension Feedback: It may be necessary to prioritize questions because older adults become tired more easily than younger people. The prioritization of questions asked of an older adult is not indicated by older adults knowing which subjects are more important, having longer health histories, or taking more medications. 15. When dealing with a patient who has impaired hearing, where would the nurse sit to facilitate lip reading? A) Halfway across the room from the patient B) Next to patient on the side from which he or she hears best C) Closer to the patient than the nurse normally would D) Knee to knee directly in front of the patient Ans: C Age Group: All Age Groups Chapter: 2
Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 7 Page and Header: 32, Patients with Hearing Impairment Taxonomic Level: Application Feedback: The nurse sits closer to patients with hearing impairment to facilitate a setting for lip reading. He or she uses regular speech volume and lip movement but may speak slightly more slowly. If a patient does not understand, the nurse uses other wording because the sounds involved may be better decoded. 16. Patients in health care settings often are anxious. What behaviour would lead a nurse to believe that a patient may be anxious? A) Short, precise answers B) Constant eye contact C) Defensive tone D) Quiet voice Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 7 Page and Header: 33, Patients with Anxiety Taxonomic Level: Analysis Feedback: Behaviours that indicate anxiety are nail-biting, foot-tapping, sweating, and pacing. The patient's voice may quiver, speech may be rapid, and language or tone may be defensive. These behaviours may be an attempt to relieve anxious feelings. Short answers, eye contact, and a quiet voice are not necessarily indications of anxiety. 17. Nurses weave the individualization of the patient interview through all aspects of the encounter. Consequently, the nurse should avoid assuming that patients follow particular cultural beliefs. In place of making this assumption, what should a nurse do? A) Assess the degree to which the patient perceives his or her cultural beliefs B) Assess how acculturated the patient is C) Know the mores of the dominant culture D) Know his or her own cultural beliefs Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual
Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 8 Page and Header: 28, Intercultural Communication Taxonomic Level: Application Feedback: The nurse should avoid assuming that patients follow cultural beliefs and assess the degree to which each individual perceives those beliefs. Assessment of acculturation and knowledge of the nurse's own cultural beliefs do not necessarily achieve this. 18. When a nurse conducts an interview with a patient, what is the primary underlying purpose? A) To provide therapeutic communication when indicated B) To prioritize the patient's medical issues C) To assess the patient's functional status D) To identify the patient's diagnoses Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 8 Page and Header: 27, Professional Communication Taxonomic Level: Application Feedback: The nurse's role related to interviewing is to gather information to assess the patient's health status and to provide therapeutic communication when indicated. The other options are incorrect as they are not the purpose of the nursing interview. 19. When a patient responds to a question with a “yes” or “no” answer, what appropriate responses by the nurse encourage the patient to elaborate? A) “Go on” B) “I see” C) “Okay” D) “That's interesting” Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 24, Encouraging Elaboration (Facilitation) Taxonomic Level: Application
Feedback: These responses encourage patients to say more and continue the conversation. They show patients that the nurse is interested. The nurse may nod the head or say “Um hum,” “Yes,” or “Go on” to cue patients to keep talking. Responses of “I see”, “That's interesting,” and “Okay” do not encourage elaboration by the patient and are therefore incorrect. 20. A nurse risks indicating to patients that their concerns are not worth discussing by A) being empathetic. B) providing false reassurance. C) being sympathetic. D) giving advice. Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 3 Page and Header: 24, False Reassurance Taxonomic Level: Comprehension Feedback: By providing false reassurance, the nurse unconsciously indicates to patients that their concerns are not worth discussing. Empathy is a therapeutic response to a patient and is a positive interaction. Being sympathetic does not tend to imply that the patient's concerns are not worth discussing. Not all advice is nontherapeutic.
Chapter 3: The Health History Multiple Choice 1. During the interview process, the nurse obtains what type of data from the patient? A) Primary B) Secondary C) Objective D) Oral Ans: A Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 38, Primary and Secondary Data Sources Taxonomic Level: Comprehension Feedback: Nurses collect primary data from patients themselves. Secondary data come from family and medical records. Objective data are data that are observed, and these are not necessarily a focus of an interview. Oral data are not a discrete category of data. 2. The nurse is admitting a new patient to the unit. While reviewing old records of this patient, the nurse knows that the data being gathered are what kind of data? A) Primary B) Secondary C) Subjective D) Objective Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 1 Page and Header: 38, Primary and Secondary Data Sources Taxonomic Level: Comprehension Feedback: Charts and family members are considered secondary data sources. The patient is the source of primary data. Subjective data are data provided to the nurse
by the patient; objective data are data that the nurse observes. 3. The nursing educator is describing different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor's best answer? A) During a hospital admission B) At a clinic visit for a fall C) In the emergency department after a motor vehicle accident D) At a health screening event Ans: A Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3 Page and Header: 39, Table 3-1 Taxonomic Level: Application Feedback: The comprehensive health history takes place upon a patient's initial admission to the hospital. A comprehensive assessment would not be performed at a screening or health promotion event. Acute injuries normally necessitate a focused or emergency assessment. 4. A nurse is conducting an emergency health history of a patient who has been admitted to the emergency department following a workplace accident. What component should be prioritized in this health history? A) The patient's genetic predisposition to cancer B) The location and intensity of the patient's pain C) The patient's immunization status D) The patient's current health promotion activities Ans: B Age Group: Adult Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 3, 4 Page and Header: 39, Table 3-1 Taxonomic Level: Application Feedback: In an emergency health history, the focus is on gathering information, so that interventions can resolve the immediate problem. Consequently, pain is a priority over family history, immunizations, and health promotion, though these should be addressed at later points in care.
5. The nurse is gathering a complete history of the patient's present illness. The nurse knows that the most appropriate way to begin to gather this information is by doing what? A) Assessing the patient's vital signs B) Gathering a complete list of the patient's medications C) Asking open-ended questions D) Asking focused questions Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 40, Present Illness Taxonomic Level: Application Feedback: The nurse collects information about the present illness by beginning with open-ended questions and having patients explain symptoms. The most appropriate way to collect data about the present illness is not to assess the patient's vital signs, gather a complete list of the patient's medications, or ask focused questions. 6. A clinical instructor is discussing with a clinical group how to take a history of the patient's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer? A) Follow the cues of the patient during the interview. B) Use a written checklist to make sure you cover all necessary areas. C) Use a head-to-toe approach to make sure you do not miss anything. D) Use a focused approach, asking only about symptoms of the present illness. Ans: A Age Group: Age Groups Chapter: 3 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 5 Page and Header: 40, Present Illness Taxonomic Level: Application Feedback: Regardless of the order of data, the nurse guides the conversation following the cues of the patient and uses a mental checklist to ensure that he or she has assessed all categories before the end of history taking. The nurse would not use a written checklist during the interview, and he or she would not use a head-to-toe approach when eliciting information about the present illness. The nurse also would not focus only on the symptoms of the present illness.
7. A genogram is primarily developed in order to visually portray which of the following? A) Family values B) Family health patterns C) Family norms D) Nationalities of family members Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Family Competency Category: Changes in Health Difficulty: Easy Objective: 6 Page and Header: 42, Family History Taxonomic Level: Comprehension Feedback: A common tool used to understand family health patterns is the genogram. This graphic representation allows the nurse to map family structures and compile a large amount of information visually. Genograms make it easier for the nurse to identify the complexity of families and validate patterns pertinent to patients. 8. A group of student nurses is presenting information on Gordon's framework for assessing a patient. What type of assessment would they be talking about? A) Comprehensive B) Focused C) Functional D) Emergency Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 45, Table 3-3 Taxonomic Level: Comprehension Feedback: Functional health patterns are especially important to nursing, because they focus on the effects of health or illness on a patient's quality of life. By using this approach, the nurse can assess the strengths of a patient as well as areas needing improvement. 9. When using Gordon's framework for a health assessment, the nurse asks a patient, “Have you made any changes in your environment because of vision, hearing, or memory decrease?” What functional health pattern is the nurse assessing?
A) Level of consciousness B) Cranial nerve function C) Coping D) Cognition Ans: D Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Difficult Objective: 7 Page and Header: 45, Table 3-3 Taxonomic Level: Evaluation Feedback: A question to include in review of cognition and perception is whether the patient has made any environmental changes because of vision, hearing, or memory decrease. This does not address coping, CN function, or level of consciousness. 10. The nurse is caring for a 77-year-old woman who has been admitted with a fractured hip. While doing the admission assessment, the patient states, “I tripped over the small rug we have in front of the sink.” What learning need does this indicate? A) The need to eliminate rugs on the patient's floors. B) The need to have wall-to-wall carpeting throughout the patient's house. C) The need for the patient to use a walker when she goes into the kitchen. D) The need for the patient to be in a wheelchair. Ans: A Age Group: Older adult Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 9 Page and Header: 45, Box 3-1 Taxonomic Level: Application Feedback: The nurse performs health teaching, based on each patient's needs and priorities, and weaves health promotion and disease prevention into care. Patient teaching about wall-to-wall carpeting or use of a walker or wheelchair is not indicated for this patient. The nurse would teach this patient about the need to eliminate small rugs from the floors of her house in order to prevent future falls. 11. After completing the interview, the nurse analyzes the data collected in order to A) establish a baseline from which to start interviewing the family. B) develop nursing interventions. C) communicate information to the physician.
D)
communicate information to other staff members.
Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 10 Page and Header: 49, Applying Your Knowledge Taxonomic Level: Analysis Feedback: The nurse prioritizes, collects, and analyzes subjective and objective data and develops nursing interventions. The nurse does not use the data gathered in the patient interview as a baseline for interviewing the family or for communicating to the physician or other staff members. 12. The nursing instructor is explaining to students the difference between the language used when a nurse talks to the patient and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record? A) Document according to the orders of the physician. B) Talk to the patient and document exactly the same. C) Use medical terminology when documenting in the medical record. D) Document exactly as the patient speaks. Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Professional Practice Difficulty: Moderate Objective: 11 Page and Header: 44, Review of Systems Taxonomic Level: Application Feedback: The nurse documents in the medical record using appropriate medical terminology. When speaking with patients, the nurse uses common lay language, so that patients better understand the questions. 13. The nurse is caring for an 82-year-old man and is reviewing information obtained in the health history assessment. The nurse knows that it is particularly important to identify the pattern of illnesses and recognize how they might be related because this patient is A) in the hospital. B) stoic. C) an older adult. D) chronically ill.
Ans: C Age Group: Adult of Advanced Age Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 12 Page and Header: 49, Older Adults Taxonomic Level: Analysis Feedback: It is important to identify the pattern of the illnesses and recognize how they might be related as the patient is an older adult. The question does not state that the patient is in the hospital, stoic, or chronically ill. 14. Through what process do the patient and the nurse work together to develop a plan of care? A) Functional assessment B) Use of subjective and objective data C) Therapeutic communication D) Use of Gordon's framework Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 12 Page and Header: 38, Introduction Taxonomic Level: Application Feedback: Through therapeutic communication, the patient and the nurse work together to resolve problems by developing collaborative strategies and solutions. Therefore, options A, B, and D are incorrect. 15. A nurse is assessing a patient and collecting only the most important information. What type of assessment is the nurse performing? A) Functional B) Emergency C) Comprehensive D) Focused Ans: B Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health
Difficulty: Difficult Objective: 3 Page and Header: 39, Table 3-1 Taxonomic Level: Analysis Feedback: In an emergency assessment, nurses collect the most important information and defer obtaining details until patients are stable. They elicit the reason for seeking care along with current health problems, medications, and allergies. A functional assessment focuses on a patient's ability to perform activities of daily living and other patterns in specific areas. A comprehensive assessment involves review of the patient's overall health. A focused assessment emphasizes a specific area but may go into great detail in that area of concern. 16. A student is working with a floor nurse who is admitting a new patient to the unit. The nurse asks the patient if he has traveled outside North America in the past 12 months. The student knows that this information is part of what aspect of the comprehensive health history? A) Interests B) Present illness C) Demographical data D) History of illnesses Ans: C Age Group: All Age Groups Chapter: 3 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 39, Demographical Data or Identifying Data Taxonomic Level: Analysis Feedback: Demographical data include environmental data about exposure to contagious diseases, travel to high-risk areas, and concerns about exposure to pollution, hazards, and allergens. Asking the patient about travel does not involve inquiring about interests, present illness, or history of illnesses. 17. Why is it important for the nurse to reconcile all the hospitalized patient's medications with the medication that the patient regularly takes at home? A) So the physician can correctly assess the patient B) So the patient's medication record correlates with the patient's medication history C) So the patient continues taking the correct drugs D) So the physician can make sure to change the patient's drugs Ans: C Age Group: All Age Groups Chapter: 3