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Chapter 1: The context and frameworks of health assessment MULTIPLE CHOICE 1. The nurse asks their client about family history of cardiovascular disease. What type of data would this be classified as? a. Objective b. Subjective c. Informed d. Precise ANS: b What the person states about themselves is considered subjective data. REF: Page 2 2. The nurse observes their client’s respiratory rate. What type of data would this be classified as? a. Objective b. Subjective c. Informed d. Precise ANS: a Data gathered by observing, inspecting, percussing, palpating and auscultation is considered objective data. REF: Page 2 3.
According to the World Health Organization, what is health defined as? a. The presence of wellbeing and absence of disease b. Situations in which people are born, grow and live c. The state of complete physical, mental and social well-being d. The absence of disease and infirmity ANS: c The World Health Organization (WHO) (2019) defines health as ‘a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity’. REF: Page 2
4. Which of the following is NOT a recognition of the social model of health? a. The importance of health promotion and disease prevention.
Test Bank b. The importance of encouraging a healthy lifestyle. c. The social, economic and environmental determinants of health and illness. d. The importance of working with sectors outside the health sector. ANS: b The social health model recognises: • The social, economic and environmental determinants of health and illness • The importance of health promotion and disease prevention • The importance of community participation in decision making • The importance of working with working with sectors outside the health sector • That equity is an important outcome of health service intervention REF: Page 3 5. What model recognises the view of health being the absence of disease? a. Social model of health b. Biomedical model of health c. Holistic model of health d. Health promotion and disease prevention ANS: b The biomedical model of western tradition views health as the absence of disease. REF: Page 3 6. What standard of care do consumers have the right to expect in Australia? a. Clients with private health insurance receive priority. b. Every person has the right of the highest standard of care. c. Every taxpayer has the right to the highest standard of care. d. Clients with a healthy, active lifestyle have priority over those who do not. ANS: b One of the principles of the Australian Charter of Healthcare Rights recognises that every person has the right to the highest standard of care. REF: Page 4 7. Which statement illustrates the biomedical model of western traditional views? a. Health is viewed as the absence of disease. b. Optimal health is viewed as high-level wellness. c. Health and disease are considered a cyclical process. d. The treatment of disease is nursing’s primary focus. ANS: a The biomedical model of western tradition views health as the absence of disease. REF: Page 3
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Test Bank
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Which of the following models of health aims to improve health outcomes, prevent and reduce illness and address the inequalities and disadvantage that exist within the community? a. Biomedical model b. Holistic health model c. Social model d. Wellness model ANS: c The social model of health acknowledges the effect of social, economic, cultural and political factors and conditions on a person’s state of health and wellbeing. REF: Page 3
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Chapter 02: Critical thinking in health assessment MULTIPLE CHOICE 1. After completing an initial assessment on a patient, the nurse has charted that his respirations are eupnoeic and his pulse is 58. This type of data would be: a. objective. b. reflective. c. subjective. d. introspective. ANS: a Objective data are what the health professional observes by inspecting, percussing, palpating and auscultating during the physical exam. REF: Page 12 2. A patient tells the nurse that he is very nervous, that he is nauseated, and that he ‘feels hot’. This type of data would be: a. objective. b. reflective. c. subjective. d. introspective. ANS: c Subjective data are what the person says about themself during history taking. REF: Page 12 3. Novice nurses, without a background of skills and experience to draw from, are more likely to make their decisions using: a. intuition. b. a set of rules. c. articles in journals. d. advice from supervisors. ANS: b Novice nurses operate from a set of rules. REF: Page 14
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Expert nurses learn to attend to a pattern of assessment data based on past experiences. This is referred to as: a. intuition. b. the nursing process. c. clinical knowledge. d. diagnostic reasoning. ANS: a Intuition is characterised by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. REF: Page 14
5. Which critical thinking skill helps the nurse to see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant ANS: b Clustering related cues helps the nurse to see relationships among the data. REF: Page 12 6. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the: a. nursing diagnosis. b. medical diagnosis. c. admission diagnosis. d. collaborative diagnosis. ANS: a An accurate nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. REF: Page 13 7. What is the step of the nursing process that includes data collection by health history, physical examination and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment ANS: d Data collection, including performing the health history, physical examination and interview, is the assessment step of the nursing process. REF: Page 12 8. When nursing diagnoses are being classified, which of the following would be considered a potential health diagnosis?
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Test Bank a. b. c. d.
Identifying existing levels of wellness. Evaluating previous problems and goals. Identifying potential problems the individual may develop. Focusing on strengths and reflecting an individual’s transition to higher levels of wellness.
ANS: c Potential health diagnoses are potential problems that an individual does not currently have but is particularly vulnerable to develop. REF: Page 13 9.
Which term best describes a proficient nurse? a. A nurse who has little experience with a specified population and uses rules to guide performance. b. A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. A nurse who sees actions in the context of daily plans for patients. d. A nurse who understands a patient situation as a whole rather than a list of tasks and sees long-term goals for the patient. ANS: d The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than as a list of tasks and is able to see how today’s nursing actions apply to the point the nurse wants the patient to reach at a future time. REF: Page 14
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Chapter 03: Developmental tasks across the life span MULTIPLE CHOICE 1. If a mother hides a block under her baby’s blanket and the baby looks for it, the nurse understands that the baby has begun to develop the concept of: a. relativism. b. object prehension. c. separation anxiety. d. object permanence. ANS: d Gradually the infant learns that objects and people continue to exist even when they are no longer in sight. This starts at about 7 months when the infant searches for an object that is partially hidden but does not search for one completely out of sight. REF: Page 18 2. A baby can sit alone before they are able to crawl. This is true because development of gross motor skills: a. occurs in a cephalocaudal direction. b. occurs in a distal to proximal direction. c. is generally the result of a baby’s chronological age. d. is simply the result of the baby’s increased desire to move. ANS: a A baby’s development of gross motor skills is predictable because it follows the direction of myelinisation (laying down of myelin) in the nervous system, cephalocaudal (head to foot direction), and proximodistal (central to peripheral direction or midline before extremities). REF: Page 19 3. Being able to think about history and philosophy and analyse and use scientific reasoning corresponds to which of Piaget’s stages? a. Formal operations b. Sensorimotor skills c. Concrete operations d. Preoperational skills ANS: a
Test Bank Adolescence corresponds to Piaget’s fourth stage, in which the person focuses on formal operations and the ability to develop abstract thinking, deal with hypothetical situations and make logical conclusions from reviewing evidence. The adolescent is no longer limited to the present but can ponder the lessons of the past and the possibilities of the future. The adolescent now can analyse and use scientific reasoning. REF: Page 29 4. The developmental crisis of generativity versus stagnation could be resolved by: a. travelling around the world. b. having and raising a family. c. buying a large house and filling it with loved belongings. d. changing jobs frequently to get a feel for what was ‘missed in youth’. ANS: b Erikson believed that during the middle years adults have the urge to contribute to the next generation. This need can be fulfilled either by producing the next generation or by producing something to pass on to the next generation. REF: Page 32 5.
Which of the following statements best describes the tasks of late adulthood? a. Older adults must quickly try to resolve the conflicts of earlier times. b. Older adults must accept that they cannot change the past and make peace with their lives. c. Older adults generally feel great sadness and worry about death; this allows them to accept their mortality. d. Older adults must never feel satisfied with their lives because it gives them goals to achieve in the future. ANS: b This period relates to Erikson’s last stage, with its key polarity of integrity versus despair. A successful resolution to this final conflict occurs when the adult accepts ‘one’s one and only life cycle as something that had to be and that, by necessity, permitted of no substitutions’ (1963). The adult feels content with their one life on earth, satisfied that if it were possible to do it over again, they would live it the same way. REF: Page 35 6. A 24-month-old child comes to the clinic for a well-child visit. His mother describes him as a child who falls apart if she changes even the smallest thing in his environment. The nurse tells his mother that this behaviour: a. is unusual in a toddler because negativism generally doesn’t emerge until age 3. b. indicates that he is insecure and probably hasn’t successfully developed trust in infancy. c. can be expected from a toddler because they typically experience ritualism
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Test Bank and global thinking. d. indicates that he has been spoiled and she should change things in his environment often to get him used to it. ANS: c Ritualism emerges with negativity. A 2-year-old wants things done in the same way; any change in schedule is upsetting. Another mark of the toddler’s sensitivity to change is global thinking. A change in one small part (such as a minor shift in room arrangement) changes the whole environment, and the 2year-old child’s equanimity disintegrates. REF: Page 23 7. The nurse is teaching a class to day care providers. Which of the following statements about growth, development and preschoolers should be included? a. Preschoolers are highly egocentric. b. They are capable of delayed imitation. c. They are still very unaware of gender and sex. d. Preschoolers ‘pretend’ to reduce anxiety about their sex roles. ANS: b Piaget’s preoperational stage covers age 2 to 7 years, a longer span than the preschool years. It is characterised by symbolic function because the child now uses symbols to represent people, objects and events. The symbolic function is revealed in child’s play, as in delayed imitation. REF: Page 24 8. An infant weighs 3.2 kg at birth. At the well-child visit 6 months later, the nurse would expect the infant to weigh at least: a. 5.4 kg. b. 6.3 kg. c. 7.7 kg. d. 9.5 kg. ANS: b Growth spurts double the birth weight by 4 to 6 months and triple the birth weight by 1 year. REF: Page 18 9. Erikson’s stage of integrity versus despair could be described as: a. an adjustment to the tasks of middle age. b. being productive and contributing to society. c. cataloguing life events to gain a sense of satisfaction. d. a time to review career goals and possibly change paths to avoid despair. ANS: c One important task of late adulthood is performing a life review. Erikson’s last ego stage has the key conflict of integrity versus despair. A successful resolution to this conflict occurs when the adult feels satisfied with their own life.
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Test Bank REF: Page 35 10. Physical growth is most rapid during which period? a. Birth to 1 year of age b. 3 to 5 years of age c. 6 to 10 years of age d. 16 to 18 years of age ANS: a The first year is the most dramatic period of growth and development. Height, weight and head circumference reflect physical growth and are sensitive indicators of an infant’s general health. REF: Page 17 11. The nurse is observing a mother with her 2-year-old child. In a period of just a few minutes the child has said ‘No’ to her many times. He even says ‘No’ when he would like to have said ‘Yes’. Which statement about this child’s behaviour is true? a. He is very spoiled and needs to be punished. b. He is a toddler and is exhibiting ritualistic behaviour. c. He is trying to assert his autonomy through negativism. d. He is just trying to test his limits and see how far he can get. ANS: c As they test their powers, they sometimes clash with their parents’ restrictions, and a battle of wills results. ‘No’ seems to be their favourite word. This negativism is a normal part of the quest for autonomy. REF: Page 23 12. Finding a partner or committing one’s life to a cause indicates successful resolution of which of Erikson’s stages? a. Intimacy versus isolation b. Identity versus role confusion c. Generativity versus stagnation d. Autonomy versus shame and doubt ANS: a Once self-identity is established after adolescence, it can be merged with another’s in an intimate relationship. During the early 20s the adult seeks the love, commitment and intimacy of a lasting relationship. REF: Page 32 13. The mother of a 2-month-old baby reports that she often lets the baby ‘cry it out’ instead of going to her in the middle of the night. In talking over this practice with her, the nurse should make her aware that: a. 2-month-old babies are old enough to learn to sleep through the night. b. babies can become spoiled if they’re picked up in the middle of the night. c. babies are developing a sense of trust and need to be responded to when they cry.
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Test Bank d. babies are just developing the ability to manipulate and should not be picked up if it is unnecessary. ANS: c Erikson viewed the mother as the primary caregiver. The crucial element in this stage (trust vs mistrust) then, is the quality of the mother–child relationship. When the mother is responsive and consistent in her nurturing, the infant learns trust. REF: Page 18 14. An 8-year-old boy’s father is very interested in seeing his child succeed in soccer. During the assessment, the nurse finds out that the child is a small boy who expresses a sincere interest in playing chess and who feels like a failure at soccer. Which statement is true in regard to this situation? a. This father needs to decrease his expectations for his son. b. This father needs to encourage his son to participate in team sports. c. This child obviously has an introverted personality and should be ‘left alone’. d. This child should be given opportunities to achieve success in any area he chooses. ANS: d Real achievement at this stage (industry vs inferiority) builds a feeling of confidence, competence and industry. The reality is that no one can master everything. If the child believes that they cannot measure up to society’s expectations, the child loses confidence and does not take pleasure in the work. REF: Page 26 15. The nurse is testing a 10-year-old child’s ability to understand conservation of matter. Which test would be appropriate? a. Ask her to sort blocks by colour and by shape. b. Ask her to order the blocks from smallest to biggest. c. Ask her to determine which glass of water has more water in it, the tall skinny glass or the short fat glass. d. Ask her to make a code using the alphabet and then write a message in the code she has made up. ANS: c Understanding conservation of matter is the ability to tell the difference between how things seem and how they really are. It is the ability to see that mass or quantity stays constant even though shape or position is transformed. REF: Page 26 16. An adolescent is beginning to develop the ability to deal with hypothetical situations and abstract thinking. The nurse would consider this finding: a. advanced for this patient’s age. b. an expected finding only in the elderly. c. a normal finding during this stage of development. d. abnormal because abstract thinking should begin to take place in early
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Test Bank childhood. ANS: c In adolescence, thinking is no longer concrete. Adolescents can analyse and use scientific reasoning. REF: Page 29 17. The stage of early adulthood (20 to 40 years) is concerned with emancipation from parents and building an independent lifestyle. Tasks of this era include: a. pursuing activities enjoyed during childhood. b. assisting younger siblings with gaining their identity. c. forming an intimate bond with another and choosing a mate. d. becoming more involved with activities in their family of origin. ANS: c Tasks of early adulthood include such things as growing independent from the parents’ home, establishing a career, forming an intimate bond with another and choosing a mate, managing one’s own household and forming a meaningful philosophy of life. REF: Page 31 18. Normal physical changes that occur during middle adulthood (40 to 64 years) include: a. deterioration of internal organ systems. b. increased muscle tone and decreased muscle strength. c. increased abdominal fat deposits from decreased activity. d. decreased sensory function and visual changes for far vision. ANS: c During middle adulthood, the hair thins, an abdominal paunch grows from increased fat deposits and decreased activity, most organ systems remain constant and sensory function remains intact except for some visual changes for near vision. REF: Page 33 19. Which of the following is an appropriate developmental task for a toddler (age 1 to 3 years)? a. Taking a place in a peer group b. Identifying sex roles and their function c. Tolerating separation from the mother or parent d. Building self-esteem and a positive self-concept ANS: c Tolerating separation from the mother or parent is a developmental task for the toddler. The others listed are for the preschool child (response 2) and the school-age child (responses 1 and 4). REF: Page 22
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Test Bank 20. A 42-year-old woman has come in for counselling. As the nurse administers the Hassles and Uplifts Scale questionnaire, the woman is told that this tool: a. will indicate the level of stress in her life. b. will show her areas of self-improvement needed to regain control in her life. c. is unable to measure stress but can help her cope with the day-to-day hassles of life. d. may show a relationship between daily stress and the occurrence of physical health problems. ANS: d Research has shown a significant relationship between daily stress and concurrent or later occurrence of physical health problems. REF: Page 37 21. A mother notes that her 4-year-old child often chatters to herself while playing alone. She is worried that her child has a psychological problem. The nurse explains to her that: a. she is just imitating what she hears around her. b. this happens when a child is lonely or needs a playmate. c. there is a concern about her child’s psychological development and further testing will be required. d. this private speech is normal at this age and is a problem-solving tool as she works through unfamiliar situations. ANS: d Children will chatter to themselves between the ages of 4 to 6 years, and this private speech is a problem-solving tool that is beneficial as they try new tasks or work through unfamiliar situations. REF: Page 24 22. During which age is belonging to a peer group considered a key socialising agent? a. The preschool years b. The school-age years c. Early adulthood d. Middle adulthood ANS: b During middle childhood, the peer group is a key socialising agent. The child begins to prefer peer group activities to activities with the parents. REF: Page 26 23. A new mother asks the nurse, ‘Why does my baby cry so much?’ Which statement by the nurse is correct? a. ‘You need to try to hold your baby for longer periods of time.’ b. ‘This means he is hungry. He needs to be fed more.’ c. ‘Your baby uses crying to tell us if he feels hungry, uncomfortable or lonely.’ d. ‘We should examine him for signs of illness.’
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Test Bank ANS: c Crying is the infant’s first means of communication. For the first month, cries are undifferentiated. After 1 month of age, the infant alters the crying pitch and intensity to reflect hunger, discomfort or loneliness. REF: Page 19 24. At what age should the nurse expect to see an infant exhibiting social smiles? a. At birth b. At 2 weeks of age c. At 4 weeks of age d. At 6 to 8 weeks of age ANS: d The social smile erupts at age 6 to 8 weeks. REF: Page 20
MULTIPLE RESPONSE 25. Which of the following physical changes are appropriate for a school-age child? Select all that apply. a. Primary teeth are lost. b. Body fat increases. c. Bone replaces cartilage. d. Appearance is slimmer than in younger children. e. Lordosis is common. ANS: a, c, d During the school-age years, bone replaces cartilage, primary teeth are lost and the child appears relatively slimmer than younger children because of proportionally longer legs, diminishing body fat and a lower centre of gravity. The other responses do not apply to this age. REF: Page 26
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Chapter 04: Cultural safety MULTIPLE CHOICE 1. One aspect of society’s value orientation concerns the dimension of time. An example of a person with ‘present’ time value orientation would be: a. a patient with a total hip replacement who has not been able to plan for discharge. b. a patient with leukaemia who continually seeks the latest medication and treatments. c. a patient who feels loss after an amputation but is looking forward to finding out about prosthetic limbs. d. a newly diagnosed diabetic who seeks a consultation with a tribal elder who can contact ancestral spirits for guidance. ANS: a The focus may be on the present, with little attention being paid to the past or the future. These individuals are concerned with ‘now’ and the future is perceived as vague or unpredictable. The nurse may have difficulty encouraging these individuals to prepare for the future. REF: Page 56 2. Which statement is accurate regarding one’s ethnicity? a. Ethnicity is dynamic and ever-changing. b. Ethnicity is the belief in a higher power. c. Ethnicity pertains to a social group within the social system that claims shared values and traditions. d. Ethnicity is learned from birth through the processes of language acquisition and socialisation. ANS: c Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, shared values, traditions, symbols or food preferences. Answers a and d refer to culture, and answer b refers to religion. REF: Page 47 3. A woman who has lived in Australia for a year after moving from Europe has learned to speak English and is almost finished with her university degree. She now dresses like her peers and says that her family ‘back home’ would hardly recognise her. This illustrates:
Test Bank a. b. c. d.
assimilation. heritage consistency. biculturalism. acculturation.
ANS: a Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture. REF: Page 55 4. A patient is in the hospital with a new diagnosis of lung cancer. He is anxious and talks to his oncologist about getting the ‘latest and best treatment out there’. This reflects which time orientation? a. Circular time b. Historical time ANS: b People who are focused on the future value see time as linear with a past, present and future. These people see time as progress and change and will inquire about the ‘latest’ treatments and most modern equipment available for a problem. REF: Pages 56 5. A physician in the clinic is frequently bothered when patients arrive late for appointments. He is so irritated by this behaviour that he often finds it hard to provide appropriate care to these individuals. What should he do first in trying to overcome his difficulty? a. Identify the meaning of health to the patient. b. Understand that these cultural practices are helpful to the patient. c. Allow the patients to arrive late and build this into his schedule. d. Examine his own culturally based values, beliefs, attitudes and practices. ANS: d The first step in understanding the healthcare needs of others is to understand one’s own culturally based values, beliefs, attitudes and practices. REF: Page 59 6. The germ theory, which posits that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? a. Holistic b. Biomedical c. Naturalistic d. Magico-religious ANS: b
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Test Bank Among the biomedical explanations for disease is the germ theory, which posits that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. REF: Page 56 7. Illness is seen as a part of life’s rhythmic course and as an outward sign of disharmony within. This statement most accurately reflects the views about illness from the: a. naturalistic theory. b. biomedical theory. c. reductionist theory. d. magico-religious theory. ANS: a The naturalistic perspective states that the laws of nature create imbalances, chaos and disease. From the perspective of the Chinese, for example, illness is not seen as an introducing agent but as a part of life’s rhythmic course and as an outward sign of disharmony within. REF: Page 56 8. An individual who takes the magico-religious perspective of illness and disease is likely to believe that their illness was caused by: a. germs and viruses. b. supernatural forces. c. eating imbalanced foods. d. an imbalance within their spiritual nature. ANS: b One of the major ways in which people view the world and explain the causation of illness is from a magico-religious perspective. The basic premise of this explanatory model is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. REF: Page 56 9. An elderly Italian-Australian woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: a. contact the hospital administrator about the best course of action. b. automatically get a priest for her. c. further assess her cultural beliefs and offer her assistance in contacting a priest if she desires. d. ask the family what they would like to do because Italian-Australians traditionally give control of decisions to their families. ANS: c
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Test Bank In addition to seeking help from the biomedical/scientific healthcare provider, patients may also seek help from folk or religious healers. Some people may believe that the cure is incomplete unless healing of body, mind and spirit are all carried out (although the division of the person into parts is itself a western concept). REF: Page 55 10. Which of the following statements is true regarding pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perception of pain, so will they vary in their expression of it. c. Cultural norms have very little to do with pain tolerance—it is always biologically determined. d. A patient’s expression of pain is largely dependent on the amount of tissue injury associated with the pain. ANS: b In addition to expecting variations in pain perception and tolerance, the nurse should also expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. REF: Page 57 11. A 30-year-old woman has recently moved to Australia with her husband. They are living with relatives until they can get a house of their own. When visitors arrive to visit with her sister, she feels suddenly shy and retreats to the back bedroom to hide until they leave. She states that this is just because she doesn’t know how to speak perfect English. This woman could be experiencing: a. culture shock. b. cultural taboos. c. cultural unfamiliarity. d. culture disorientation. ANS: a These individuals may be in various stages of culture shock, a term used to describe the state of disorientation or inability to respond to the behaviour of a different cultural group because of its sudden strangeness, unfamiliarity and incompatibility with the individual’s perceptions and expectations. REF: Page 56 12. The first step in understanding the healthcare needs of another person is: a. identifying the meaning of health to the other person. b. understanding one’s own heritage-based cultural values, beliefs, attitudes and practices relevant to health and illness. c. understanding how the healthcare delivery system works. d. being knowledgeable about the person’s social background. ANS: b
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Test Bank Understanding one’s own cultural values, beliefs, attitudes and practices related to health and illness is the first step to understanding the healthcare needs of others. The other possible answers listed are subsequent steps in the process. REF: Page 60
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Chapter 5: Screening for family violence and abuse MULTIPLE CHOICE 1. As a mandatory reporter of elder abuse, which of the following must be present before a nurse notifies the authorities? a. Statements from the victim b. Statements from witnesses c. Proof of abuse and/or neglect d. Suspicion of elder abuse and/or neglect ANS: d Many healthcare workers are under the erroneous assumption that proof is required before notification of suspected abuse can occur. Only a suspicion of elder abuse and/or neglect is necessary. REF: Page 66 2. The nurse is aware that intimate partner violence (IPV) screening should occur with which situation? a. When IPV is suspected b. When a woman has an unexplained injury c. As a routine part of each healthcare encounter d. When there is a known history of abuse in the family ANS: c Many nursing professional organisations have called for routine, universal screening for IPV to assist women in getting help for the problem. REF: Page 67 3. Which statement is best for the nurse to use when preparing to administer the Abuse Assessment Screen? a. ‘We are required by law to ask these questions.’ b. ‘We need to talk about whether you feel you have been abused.’ c. ‘We are asking these questions because we suspect that you are being abused.’ d. ‘We ask the following questions because domestic violence is so common in our society.’ ANS: d Such an introduction both alerts the woman that questions about domestic violence are coming and makes sure that the woman knows she is not being singled out for these questions. REF: Page 71
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4. Which term refers to a wound produced by the tearing and/or splitting of body tissue, usually from blunt impact over a bony surface? a. Abrasion b. Contusion c. Laceration d. Haematoma ANS: c The term laceration fits this definition. An abrasion is caused by rubbing of the skin or mucous membrane. A contusion is injury to tissues without breakage of skin and a haematoma is a localised collection of extravasated blood. REF: Page 77 5. During an examination, the nurse notices a patterned injury on a patient’s back. Which of the following would cause such an injury? a. Blunt force b. Friction abrasion c. Stabbing from a kitchen knife d. Whipping from an extension cord ANS: d A patterned injury is an injury caused by an object that leaves a distinct pattern on the skin and/or organ. REF: Page 77 6. When documenting intimate partner violence and elder abuse, the nurse should include: a. photographic documentation of injuries. b. a summary of the abused patient’s statements. c. verbatim documentation of every statement made. d. a general description of injuries in the progress notes. ANS: a Documentation of intimate partner violence and elder abuse must include detailed nonbiased progress notes, the use of injury maps and photographic documentation. Written documentation needs to be verbatim, within reason. Not every statement can be documented. REF: Pages 77 7. A female patient has denied any abuse when answering the Abuse Assessment Screen, but the nurse has noticed some other conditions that are associated with intimate partner violence. Examples of such conditions include: a. asthma. b. confusion. c. depression. d. frequent colds. ANS: c
Test Bank Depression is one of the conditions that is particularly associated with intimate partner violence. REF: Page 67 8. When assessing bruising, which colour indicates a new bruise that is less than 2 hours old? a. Red b. Purple-blue c. Greenish-brown d. Brownish-yellow ANS: a A new bruise is usually red and will often develop a purple or purple-blue appearance 12 to 36 hours after blunt-force trauma. The colour of bruises (and ecchymoses) generally progresses from purple-blue to bluish-green to greenishbrown to brownish-yellow before fading away. REF: Page 76 9. The nurse suspects abuse when a 10-year-old child is taken to Emergency for a leg injury. The best way to document the history and physical findings is to: a. write what the child’s caregiver tells the nurse. b. use the words the child used to describe how the injury occurred. c. write what the nurse observes during the conversation. d. rely on photographs of the injuries. ANS: b When documenting the history and physical findings of child abuse and neglect, use the words the child has given to describe how their injury occurred. Remember that the possibility arises that the abuser may be accompanying the child. REF: Page 77 10. During an interview, a woman has answered ‘yes’ to two of the Abuse Assessment Screen questions. What should the nurse say next? a. ‘I need to report this abuse to the authorities.’ b. ‘Tell me about this abuse in your relationship.’ c. ‘So you were abused?’ d. ‘Do you know what caused this abuse?’ ANS: b If a woman answers ‘yes’ to any of the Abuse Assessment Screen questions, the nurse should ask questions designed to assess how recent and how serious the abuse was. Asking the woman to ‘tell me about this abuse in your relationship’ is a good way to start. REF: Page 72
Test Bank MULTIPLE RESPONSE 11. The nurse is assessing an elderly woman and suspects abuse. Which questions are appropriate for screening for abuse? Select all that apply. a. ‘Has anyone at home ever pushed you, hit you or hurt you?’ b. ‘Are you being abused?’ c. ‘Are you alone a lot?’ d. ‘Are you afraid of anyone at home?’ e. ‘Has anyone ever failed to help you take care of yourself when you needed help?’ ANS: a, c, d, e The questions in options a, c, d and e are among the questions recommended by the New Zealand Standards Council when screening for elder abuse. REF: Page 75
Chapter 07: The health assessment interview MULTIPLE CHOICE 1. The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, the nurse knows which statement is more accurate? The woman is: a. excited about her pregnancy but nervous about labour. b. exhibiting verbal and nonverbal behaviour that does not match. c. excited about her pregnancy but her husband is not and this is upsetting to her. d. not excited about her pregnancy but believes the nurse will respond negatively to her if she states this. ANS: b Communication is all behaviour, conscious and unconscious, verbal and nonverbal. All behaviour has meaning. REF: Page 92 2. Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a healthcare professional? a. A well-adjusted adolescent in for a sports physical. b. A recovering alcoholic in for a basic physical examination. c. A man whose wife has just been diagnosed with lung cancer. d. A hearing-impaired man who uses sign language to communicate and has an interpreter with him. ANS: c The receiver attaches meaning determined by their past experiences, culture, self-concept and current physical and emotional states. REF: Page 92 3. Because the physical environment in which an interview takes place is an important consideration for the success of an interview, the interviewer should: a. reduce noise by turning off the television and radio. b. place the distance between the interviewer and the patient about half a metre or closer. c. provide a dim light that makes a room cosier and will help the patient relax.
Test Bank d. arrange seating across a desk or table to allow the patient some personal space. ANS: a Reduce noise. Multiple stimuli are confusing. Turn off the television, radio and any unnecessary equipment. REF: Page 93 4. In an interview, the nurse may find it necessary to take notes to aid their memory later. Which of the following statements is true regarding note-taking? a. Taking notes may impede the nurse’s observation of the patient’s nonverbal behaviours. b. Taking notes allows the patient to continue at their own pace as the nurse records what is said. c. Taking notes allows the nurse to shift attention away from the patient, resulting in increased comfort level. d. Taking notes allows the nurse to break eye contact with the patient, which may increase their level of comfort. ANS: a Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often; it shifts attention away from the patient, diminishing their sense of importance. It can interrupt the patient’s narrative flow and it impedes the observation of the patient’s nonverbal behaviour. REF: Pages 94 5. The following statement could be found at which phase of the interview? ‘Mr S, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here.’ a. During the summary b. Closing the interview c. During the body of the interview d. Opening/introducing the interview ANS: d When gathering a complete history, give the reason for the interview during the opening or introduction of the interview. REF: Page 94 6. A woman, Mrs H, has just entered the emergency department after being battered by her husband. The nurse will need to get some information from her to begin treatment. What is the best choice for an opening with this patient? a. ‘Nancy, my name is Mrs C.’ b. ‘Hello, Mrs H, my name is Mrs C. It is really cold today!’ c. ‘Mrs H, my name is Mrs C. You sure look like you’re in pain, can I get you anything?’ d. ‘Mrs H, my name is Mrs C. I’ll need to ask you a few questions about what
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Test Bank happened.’ ANS: d Address the person, using their surname. Introduce yourself and state your role in the agency. Friendly small talk is not needed to build rapport. REF: Page 94 7. During an interview, the nurse states: ‘You mentioned shortness of breath. Tell me more about that’. Identify the verbal skill used with this statement. a. Reflection b. Facilitation c. Direct question d. Open-ended question ANS: d The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. Use it to begin the interview, to introduce a new section of questions and whenever the person introduces a new topic. REF: Page 94 8. A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalisations is missing. Which statement by the nurse would be most appropriate to gather these data? a. ‘Mr Y, at your age, surely you have been hospitalised before!’ b. ‘Mr Y, I just need permission to get your medical records from your prior treatment facility.’ c. ‘Mr Y, you mentioned that you have been hospitalised on several occasions. Would you tell me more about that?’ d. ‘Mr Y, I just need to get some additional information about your past hospitalisations. When was the last time you were admitted for chest pain?’ ANS: d Use direct questions after the person’s opening narrative to fill in any details they left out. Also use direct questions when specific facts are needed, such as when asking about past health problems or during the review of systems. REF: Page 95 9. When taking a history from a newly admitted patient, the nurse notices that he is pausing often and looking at the nurse expectantly. What would be the nurse’s best response to this behaviour? a. Be silent and allow him to continue when he is ready. b. Smile at him and say, ‘Don’t worry about all of this. I’m sure we can find out why you’re having these pains.’ c. Lean back in the chair and ask, ‘Mr J, you are looking at me in a strange way; there isn’t anything wrong, is there?’ d. Stand up and say, ‘I can see that this interview is uncomfortable for you. We can continue it another time’.
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Test Bank
ANS: a Silent attentiveness communicates that the person has time to think, to organise what they wish to say without interruption from you. This ‘thinking silence’ is the one health professionals interrupt most often. REF: Page 95 10. A woman is discussing the problems she is having with her 2-year-old son. ‘He won’t go to sleep at night and during the day he has several fits. I get so upset when that happens’. The nurse’s best verbal response would be: a. ‘Go on, I’m listening.’ b. ‘Fits? Tell me what you mean by this.’ c. ‘Yes, it can be upsetting when a child has a fit.’ d. ‘Don’t be upset when he has a fit; every 2-year-old has fits.’ ANS: b Use clarification when the person’s word choice is ambiguous or confusing (e.g. ‘Tell me what you mean by “tired blood”.’). Clarification is also used to summarise the person’s words, simplify the words to make them clearer, and then ask if you are on the right track. REF: Page 96 11. A 17-year-old single mother is describing how difficult it is to raise a 2-year-old by herself. During the course of the interview she states, ‘I can’t believe my boyfriend left me to do this by myself! What a terrible thing to do to me!’ Which of the following responses by the nurse uses empathy? a. ‘You feel alone?’ b. ‘You can’t believe he left you alone.’ c. ‘It must be so hard to face this all alone.’ d. ‘I would be angry, too; raising a child alone is no picnic.’ ANS: c An empathic response recognises the feeling and puts it into words. It names the feeling and allows the expression of it. It strengthens rapport. Other empathic responses are, ‘This must be very hard for you’, ‘I understand’ or just placing your hand on the person’s arm. REF: Page 96 12. A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco and drug use. When the nurse asks him about tobacco use, he states, ‘I quit smoking after my wife died 7 years ago.’ However, the nurse notices an open package of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. ‘Mr K, I know that you are lying.’ b. ‘Mr K, come on, tell me how much you smoke.’ c. ‘Mr K, I didn’t realise your wife had died. It must be difficult for you at this time. Please tell me more about that.’
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Test Bank d. ‘Mr K, you have said that you don’t smoke, but I see that you have an open package of cigarettes in your pocket.’ ANS: d In the case of confrontation, a certain action, feeling or statement has been observed, and you now focus the person’s attention on it. You give your honest feedback about what you see or feel. This may focus on a discrepancy. Or you may confront the person when you notice parts of the story are inconsistent. REF: Page 96 13. The nurse has used interpretation regarding a patient’s statement or actions. After using this technique, it would be best for the nurse to: a. apologise because this can be demeaning for the patient. b. allow the patient time to confirm or correct the inference. c. continue with the interview as though nothing had happened. d. immediately restate the nurse’s conclusion on the basis of the patient’s nonverbal response. ANS: b Interpretation is not based on direct observation as is confrontation, but it is based on one’s inference or conclusion. You do run a risk of making the wrong inference. If this is the case, the person will correct it. But even if the inference is corrected, interpretation helps to prompt further discussion of the topic. REF: Page 96 14. During an interview, a woman says, ‘I have decided that I can no longer allow my children to live with their father’s violence. I just can’t seem to leave him, though’. Using interpretation, the nurse’s best response would be: a. ‘You’re going to leave him?’ b. ‘If you’re afraid for your children, why can’t you leave?’ c. ‘It sounds as if you might be afraid of how your husband will respond.’ d. ‘It sounds as though you have made your decision. I think it is a good one.’ ANS: c This statement is not based on one’s inference or conclusion. It links events, makes associations or implies cause. Interpretation also ascribes feelings and helps the person understand their own feelings in relation to the verbal message. REF: Page 96 15. A pregnant woman states, ‘I just know labour will be so painful that I won’t be able to stand it. I know it sounds awful, but I really dread going into labour.’ The nurse responds by stating, ‘Oh, don’t worry about labour so much. I have been through it and although it is painful there are many good medications to decrease the pain.’ Which statement is true regarding this response? a. It was a therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. It was a nontherapeutic response. By providing false reassurance, the nurse
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