Physical Examination and Health Assessment 8th Edition Chapter 1 - Evidence-Based Assessment 3 Physical Examination and Health Assessment 8th Edition
Chapter 2 - Cultural Assessment
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Chapter 3 - The Interview
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Chapter 4 - The Complete Health History
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Chapter 5 - Mental Status Assessment
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Chapter 6 - Substance Use Assessment
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Chapter 7 - Domestic and Family Violence Assessment
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Chapter 8 - Assessment Techniques and Safety in the Clinical Setting
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Chapter 9 - General Survey and Measurement
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Chapter 10 - Vital Signs
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Chapter 11 - Pain Assessment
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Chapter 12 - Nutrition Assessment
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Chapter 13 - Skin Hair and Nails
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Chapter 14 - Head Face Neck and Regional Lymphatics
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Chapter 15 - Eyes
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Chapter 16 - Ears
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Chapter 17 - Nose Mouth and Throat
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Chapter 18 - Breasts Axillae and Regional Lymphatics
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Chapter 19 - Thorax and Lungs
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Chapter 20 - Heart and Neck Vessels
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Chapter 21 - Peripheral Vascular System and Lymphatic System
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Chapter 22 - Abdomen
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Chapter 23 - Musculoskeletal System
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Chapter 24 - Neurologic System
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Chapter 25 - Male Genitourinary System
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Chapter 26 - Anus Rectum and Prostate
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Chapter 27 - Female Genitourinary System
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Chapter 28 - The Complete Health Assessment Adult
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Chapter 29 - The Complete Physical Assessment Infant Young Child and Adolescent
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Chapter 30 - Bedside Assessment and Electronic Documentation
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Chapter 31 - The Pregnant Woman
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Chapter 32 - Functional Assessment of the Older Adult
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Chapter 01: Evidence-Based Assessment Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. After completing an initial assessment of a patient, the nurse has charted that his respirations
are eupneic and his pulse is 58 beats per minute. What type of assessment data is this? a. Objective b. Reflective c. Subjective d. Introspective ANS: A
Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type of
assessment data is this? a. Objective b. Reflective c. Subjective d. Introspective ANS: C
Subjective data is what the person says about him or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. What do the patient’s record, laboratory studies, objective data, and subjective data combine
to form? a. Database b. Admitting data c. Financial statement d. Discharge summary ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data form the database. The other items are not part of the patient’s record, laboratory studies, or data. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard.
Which action should the nurse take next? a. Notify the patient’s physician. b. Document the sound exactly as it was heard. c. Validate the data by asking another nurse to listen to the breath sounds. d. Assess again in 20 minutes to note whether the sound is still present. ANS: C
When unsure of a sound heard while listening to a patient’s breath sounds, the nurse validates the data to ensure accuracy by either repeating the assessment themselves or asking another nurse to assess the breath sounds. If the nurse has less experience analyzing breath sounds, then he or she should ask an expert to listen. When unsure of a sound heard while listening to a patient’s breath sounds, the nurse should validate the data before documenting to ensure accuracy and before notifying the patient’s physician. To validate that data, the nurse either repeats the assessment himself or herself or asks another nurse to assess the breath sounds. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. The nurse is conducting a class for new graduate nurses. While teaching the class, what
should the nurse keep in mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are more likely to base their decisions on? a. Intuition b. A set of rules c. Articles in journals d. Advice from supervisors ANS: B
Novice nurses operate from a set of defined, structured rules to make decisions. It takes time, perhaps a few years, in similar clinical situations to achieve competency and it is functioning at the level of an expert practitioner when intuition is included in making clinical decisions. Intuition is included in decision making when functioning at the level of an expert practitioner. While information in journal articles and advice from supervisors may assist in making decisions, novice nurses do not typically base their decisions on them. It would also be important that if information from journal articles and advice from supervisors were used, that they were evidence based. DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
6. The nurse is reviewing information about evidence-based practice (EBP). Which statement
best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinician’s experience. d. EBP does not consider the patient’s own preferences as important. ANS: C
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EBP is a systematic approach to practice that emphasizes the use of research evidence in combination with the clinician’s expertise and clinical knowledge (physical assessment), as well as patient values and preferences, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 7. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which
is an example of a first-level priority problem? a. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress ANS: D
First-level priority problems are those that are emergent, life-threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs). Postoperative pain, diabetic teaching for a patient newly diagnosed with diabetes, and a small laceration on sole of the foot are not considered first-level priority problems. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. When considering priority setting of problems, the nurse keeps in mind that second-level
priority problems include which of these aspects? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs ANS: C
Abnormal laboratory values are a second-level priority problem. Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security). Low self-esteem and lack of knowledge are considered third-level priority as although they are important to a patient’s health, they can be addressed after more urgent health problems are addressed. Severely abnormal vital signs would be considered a first-level priority problem. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. Which critical-thinking skill helps the nurse see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant ANS: B
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Clustering related cues involves clustering, or grouping together, assessment data that appear to be associated, or related, and helps the nurse see relationships among the data. Identifying gaps is looking for missing information and validation involves ensuring accuracy, and distinguishing relevant and irrelevant data involves identifying data the fit, or support the problem, but none of those help the nurse to see relationships. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. The nursing process is a sequential method of problem solving that nurses use and includes
which steps? a. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation ANS: D
The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having
difficulty breathing. How should the nurse prioritize these problems? a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing ANS: A
First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. Which is a barrier to incorporating EBP? a. Nurses’ lack of research skills in evaluating the quality of research studies b. Lack of significant research studies c. Insufficient clinical skills of nurses d. Inadequate physical assessment skills ANS: A
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As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. Lack of significant research studies, insufficient clinical skills of nurses, and inadequate physical assessment skills are not barriers to incorporating EBP. Instead, as individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research which are barriers to incorporating EBP. DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
13. During a staff meeting, nurses discuss the problems with accessing research studies to
incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a. Form a committee to conduct research studies. b. Post published research studies on the unit’s bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies. ANS: D
Facilitating support for EBP includes teaching the nurses how to conduct electronic searches and time to go to the library. However, the best method to help that staff incorporate evidence-based clinical decision making into their practice would be to teach them how to conduct electronic literature searches for pertinent studies may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. Although allowing time for nurses to visit the library may help to support evidence-based questions, time to do so may not be available for many nurses. A better method to facilitate support for EBP would be teaching the nurses how to conduct electronic searches. Just posting published research studies on the unit’s bulletin board does not facilitate EBP, as not all published research is valid or pertinent to the nurses’ practice. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these? a. Disease originates from the external environment. b. The individual human is a closed system. c. Nurses are responsible for a patient’s health state. d. Holistic health views the mind, body, and spirit as interdependent. ANS: D
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Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent and functioning as a whole within the environment. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. The basis of disease originates from both the external environment and from within the person; the individual human is an open system, continually changing and adapting; and each person is responsible for his or her own personal health state (not the nurse). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. The nurse recognizes that which concept of prevention is essential in describing health? a. Disease can be prevented by treating the external environment. b. The majority of deaths among Americans under age 65 years are not preventable. c. Prevention places the emphasis on the link between health and personal behavior. d. The means to prevention is through treatment provided by primary health care
practitioners. ANS: C
A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior. Although treating the environment may help in preventing some diseases, not all diseases can be prevented by treating the external environment. The majority of deaths among Americans under age 65 years are preventable. The means to prevention is achieved through counseling primary care providers designed to change people’s unhealthy behaviors r/t smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries, and sexually transmitted infections. DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
16. The nurse is performing a physical assessment on a newly admitted patient. Which is an
example of objective information obtained during the physical assessment? a. Patient’s history of allergies b. Patient’s use of medications at home c. Last menstrual period 1 month ago d. 2 × 5 cm scar on the right lower forearm ANS: D
Objective data is the patient’s record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. A patient’s history of allergies, use of medications at home, and date of last menstrual periods are all subjective data. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 17. A visiting nurse is making an initial home visit for a patient who has several chronic medical
problems. Which type of database is most appropriate to collect in this setting? a. A follow-up database
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b. A focused database c. A complete database d. An emergency database ANS: C
A complete database is collected in primary care settings, such as a pediatric or family practice clinic, independent or group private practice, college health service, women’s health care agency, visiting nurse agency, or community health agency. In these settings, the nurse is the first health professional to see the patient and has the primary responsibility for monitoring the person’s health care. A follow-up database is performed to follow up, or evaluate changes, on short-term and chronic health problems, but would be collected at appropriate intervals after a complete database was collected at the initial visit. A focused database is conducted for a limited or short-term problem, not for a patient with several chronic problems. An emergency database is an urgent, rapid collection of data often compiled concurrently while lifesaving measures are being performed. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. In which situation is it most appropriate for the nurse to perform a focused or
problem-centered history? a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for a scheduled surgery. d. Patient in an outpatient clinic has cold and influenza-like symptoms. ANS: D
In a focused or problem-centered database, the nurse collects a “mini” database, which is smaller in scope than the completed database. This mini database primarily concerns one problem, one cue complex, or one body system. A complete database should be conducted for a patient being admitted to a long-term care facility or being admitted for a scheduled surgery. An emergency database should be conducted for a patient with sudden and severe shortness of breath. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood
pressure checks since she changed medications 2 months ago. Which is the most appropriate action for the nurse to take? a. Collect a follow-up database and then check the patient’s blood pressure. b. Ask the patient to read her health record and indicate any changes since her last visit. c. Check the patient’s blood pressure. d. Obtain a complete health history on the patient before checking her blood pressure. ANS: A
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A follow-up database is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation. Asking the patient to read her health history and indicate any changes since her last visit is not appropriate. Just checking the patient’s blood pressure without following up on or assessing for any changes in the patient’s condition is inappropriate. It is not necessary to conduct a complete health history as one was conducted 2 months ago. Rather a follow-up assessment regarding the patient’s blood pressure and factors associated with it are necessary. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 20. A patient is brought by ambulance to the emergency department with multiple injuries
received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination and institute lifesaving measures. b. Simultaneously ask history questions while performing the examination and initiating lifesaving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform lifesaving measures and delay asking any history questions until the patient is transferred to the intensive care unit. ANS: B
The emergency database calls for a rapid collection of the database, often concurrently compiled with lifesaving measures. The other responses are not appropriate for the situation. This is an emergency situation and an emergency database with rapid collection of the database compiled concurrently with lifesaving measures. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination.
Why is it important for the nurse to consider the basics of the patient’s culture during the patient’s health assessment? a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. The U.S. is becoming increasingly diverse. d. Provide culturally relevant health care. ANS: D
It is important for the nurse to consider the basics of the patient’s culture in order to ask the right questions to gather data that is accurate and meaningful in order to provide culturally relevant health care. Considering the basics of a patient’s culture does not ensure the identification of the cause of a patient’s illness or an accurate disease diagnosis. Although the U.S. is becoming increasingly diverse, that is not a reason for considering the basics of the patient’s culture during the patient’s health assessment. Instead it is to provide culturally relevant health care to this patient. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity
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22. What is a focus of the health professional in the health promotion model? a. Changing people’s perceptions of disease b. Identifying biomedical model interventions c. Identifying negative health acts of people d. Teaching and helping people choose a healthier lifestyle ANS: D
In the health promotion model, the focus of the health professional is on teaching and helping the consumer choose a healthier lifestyle. Changing people’s perception of disease, identifying biomedical model interventions, and identifying negative health acts of people are not the focus of the health promotion model. In the health promotion model, the focus of the health professional is on teaching and helping the consumer choose a healthier lifestyle. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Health Promotion and Maintenance 23. Which statement best describes a proficient nurse? a. Has little experience with a specified population and uses rules to guide
performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate
solution. c. Sees actions in the context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes
the 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. The proficient nurse is able to see how today’s nursing actions can apply to the point the nurse wants the patient to reach at a future time. A nurse that has little experience with a specified population and uses rules to guide performance is a novice nurse. A nurse that has an intuitive grasp of a clinical situation and quickly identifies the accurate solution is an expert nurse. Seeing actions in the context of daily plans for patients describes competency or a competent nurse. DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: General
MULTIPLE RESPONSE 1. The nurse is reviewing data collected after an assessment. Of the data listed below, which
would be considered related cues that would be clustered together during data analysis? (Select all that apply.) a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute ANS: A, C, E, F
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Clustering related cues helps the nurse recognize relationships among the data. The cues r/t the patient’s respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues r/t bowels and peripheral edema are not r/t the respiratory cues. Hypoactive bowel sounds and +2 edema of the left hand are separate cues that do not relate to the other cues. The other cues (wheezes, cough, report of dyspnea, respiration rate and rhythm) all relate to the patient’s respiratory status. The cues of bowel sounds and peripheral edema are not r/t the respiratory cues. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care OTHER 1. Put the following patient situations in order of the level of priority (from highest priority to
lowest priority). 1. First-level priority problem 2. Second-level priority problem 3. Third-level priority problem a. A teenager who was stung by a bee during a soccer match is having trouble breathing. b. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. c. An older adult with a urinary tract infection is also showing signs of confusion and agitation. ANS:
A, C, B First-level priority problems are immediate priorities, such as trouble breathing (remember the airway, breathing, circulation priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e.g., patient education) are important to a patient s health but can be addressed after more urgent health problems are addressed. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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Chapter 02: Cultural Assessment Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. The nurse is reviewing the characteristics of culture. Which statement is correct regarding the
development of one’s culture? a. Learned through language acquisition and socialization b. Genetically determined on the basis of racial background c. A nonspecific phenomenon and is adaptive but unnecessary d. Biologically determined on the basis of physical characteristics ANS: A
Culture is a complex phenomenon that includes attitude, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It is not biologically or genetically determined and is learned by the individual. It is a universal phenomenon and is important because a person’s culture defines health and illness, identifies when treatment is needed and which treatment is acceptable, and informs a person of how symptoms are expressed and which symptoms are important. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 2. During a class on the aspects of culture, the nurse shares that culture has four basic
characteristics. Which statement correctly reflects one of the characteristics of culture? a. Static and unchanging b. Members share similar physical characteristics. c. Members share a common geographic origin and religion. d. Adapted to specific conditions r/t environmental and technical factors ANS: D
Culture has four basic characteristics, one of which is that it is adapted to specific conditions r/t environmental and technical factors and to the availability of natural resources. The other three characteristics are: (1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the cultural group; and (3) dynamic and ever changing. Culture is not static and unchanging but is dynamic and ever changing. Members of a culture do not necessarily share similar physical characteristics. Sharing similar physical characteristics refers to race. Members of a culture do not necessarily share a common geographic origin and religion. Sharing a common geographic origin and religion refers to ethnicity. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition
stating “the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society” reflects which term? a. Norms b. Culture c. Ethnicity
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d. Assimilation ANS: B
The culture that develops in any given society is unique, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit the given definition. Norms refers to the typical or usual. Ethnicity refers to a social group that may possess shared traits, such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Assimilation refers to taking on the characteristics of the dominant culture. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity 4. The nurse is discussing the term subculture with a student nurse. Which statement by the
nurse would best describe subculture? a. “Fitting as many people as possible into the majority culture.” b. “Identifying small groups of people who do not want to be identified with the larger culture.” c. “Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations.” d. “Recognizing fairly large groups of people with shared characteristics that are not common to all members of a culture.” ANS: D
Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups. Fitting as many people as possible into the majority culture, identifying small groups of people who do not want to be identified with the larger culture, and singling out groups of people who suffer differential and unequal treatment as a result of cultural variations do not describe a subculture. A subculture is a group of people with a culture that share some different beliefs, values, or attitudes than the majority of the larger culture. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that
which is the largest and fastest growing population? a. Asian b. Hispanic c. American Indian d. African American/black ANS: B
Hispanics are the largest and fastest growing population in the United States, followed by African Americans/blacks, Asians, two or more races, American Indians and Alaska natives, and other groups. DIF: Cognitive Level: Remembering (Knowledge) General
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6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to
a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospital’s safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary. ANS: A
The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from “evil spirits.” When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet’s meaning to the patient. Asking the patient to lock the item with other valuables in the hospital’s safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient’s cultural health practices. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 7. The nurse manager is explaining culturally competent care during a staff meeting. Which
statement accurately describes the concept of a culturally competent caregiver? a. Able to speak the patient’s native language b. Possesses some basic knowledge of the patient’s cultural background c. Applies the underlying background knowledge of a patient’s culture to provide the best possible health care d. Understands and attends to the total context of the patient’s situation ANS: D
Culturally competent implies that the caregiver understands and attends to the total context of the individual’s situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. It does not require the caregiver to speak the patient’s native language. Speaking the patient’s native language is not required for culturally competency. Possessing some basic knowledge of the patient’s cultural background describes cultural sensitivity. Applying underlying background knowledge of a patient’s culture to provide the best possible health care describes being culturally appropriate. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 8. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding
of the concept of ethnicity with which statement? a. “Ethnicity is dynamic and ever changing.” b. “Ethnicity is the belief in a higher power.” c. “Ethnicity pertains to a social group that may possess shared traits such as religion and language.” d. “Ethnicity is learned from birth through the processes of language acquisition and socialization.” ANS: C
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Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. 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, values, traditions, symbols, or food preferences. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 9. The nurse is comparing the concepts of religion and spirituality. Which statement describes an
appropriate component of one’s spirituality? a. Belief in and the worship of God or gods b. Being closely tied to one’s ethnic background c. Attendance at a specific church or place of worship d. A connection with something larger than oneself and belief in transcendence ANS: D
Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Belief in and the worship of God or gods and attendance at a specific church or place of worship apply to religion. Being closely tied to one’s ethnic background is not a concept of spirituality or religion. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 10. A woman who has lived in the United States for a year after moving from Europe has learned
to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Integration b. Assimilation c. Biculturalism d. Heritage consistency ANS: B
Assimilation is a unidirectional, linear process moving from unacculturated to acculturated in which a person develops a new cultural identity and becomes like members of the dominant culture. Integration and biculturalism are bidirectional and bidimensional inducing reciprocal change in both cultures and maintain in aspects of the original culture in one’s ethnic identity. There is nothing in the question to indicate that she has maintained aspects of her original culture and states that her family and friends would hardly recognize her. Nothing in the questions refers to aspects of heritage consistency, or the degree to which she has retained her original/traditional culture. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 11. The nurse is conducting a heritage assessment. Which question is most appropriate for this
assessment?
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a. b. c. d.
“Do you smoke?” “What is your religion?” “Do you have a history of heart disease?” “How many years have you lived in the United States?”
ANS: D
Asking questions about a person’s country of ancestry, years in the United States, etc. allows the nurse to assess a person’s heritage. Simply asking about one’s religion, smoking history, or health history does not reflect heritage. Simply asking about one’s religion, smoking history, or health history does not reflect heritage. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 12. The nurse is reviewing theories of illness. The germ theory, which states 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. Magicoreligious ANS: B
Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic, or holistic, perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 13. An Asian-American woman is experiencing diarrhea, which is believed to be “cold” or “yin.”
What should the nurse recognize that the woman may likely to try to treat it? a. Foods that are “hot” or “yang” b. Readings and Eastern medicine meditations c. High doses of medicines believed to be “cold” d. No treatment because diarrhea is an expected part of life ANS: A
Yin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. The other explanations do not reflect the yin/yang theory. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 14. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese
philosophy of Tao. Which statement most accurately reflects this philosophy’s view of “health”? a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfect balance.
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d. A person is able to care for others and function socially. ANS: C
Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory. According to the yin/yang theory, health is believed to exist when all aspects of the person are in perfect balance. Being able to work and produce; being happy, stable, and feeling good; and caring for others and functioning socially have do not demonstrate a balance in all aspects of a person. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 15. Illness is caused by an imbalance or disharmony in the forces of nature. This statement most
accurately reflects the views about illness from which theory? a. Germ theory b. Naturalistic theory c. Magicoreligious theory d. Biomedical or scientific theory ANS: B
The naturalistic perspective states that the forces of nature must be kept in natural balance or harmony. An imbalance in the forces of nature can cause illness. The other options are not correct. The naturalistic theory believes that illness is caused by an imbalance or disharmony in the forces of nature. The germ theory is similar to biomedical theory, both of which believe that illness or disease is caused by microorganisms. The magicoreligious theory believes that illness is caused by supernatural forces such as God or other supernatural powers. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 16. What does an individual who believes the magicoreligious theory of illness and disease
believe is the cause of his or her illness? a. Germs and viruses b. Supernatural forces c. Eating imbalanced (hot/cold) foods d. Imbalance within his or her spiritual nature ANS: B
The basic premise of the magicoreligious perspective 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. The other answers do not reflect the magicoreligious perspective. Germs and viruses refer to the biomedical theory. Eating imbalanced hot or cold food is applicable to the yin/yang naturalist theory. Imbalance within one’s spiritual nature is not considered a cause of illness in any of the theories of illness. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 17. What should the nurse, who is caring for an American Indian woman seeking help to regulate
her diabetes, anticipate or expect of the patient? a. Will comply with the treatment prescribed
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b. Has given up her belief in naturalistic causes of disease c. May also be seeking the assistance of a shaman or medicine man d. Will need extra help in dealing with her illness and may be experiencing a crisis of
faith ANS: C
Members of the American Indian culture often seek the care of a shaman or medicine man in addition to help from Western medicine. Some, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept). Oftentimes patients of a different culture, especially if there is a language barrier, do not comply with prescribed treatments. Seeking the care of a biomedical or scientific health care provider does not mean the patient has given up her belief in naturalistic causes of disease as they often seek the care of folk healing to complement the biomedical treatment. American Indians typically believe the naturalistic view of illness, not the magicoreligious theory, so the nurse should not anticipate that the patient is having a crisis of faith. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 18. An older Mexican-American woman with traditional beliefs has been admitted to an inpatient
care unit. When admitting this patient, what would a culturally sensitive nurse do? a. Contact the hospital administrator about the best course of action. b. Arrange for a shaman for her, because requesting one herself is not culturally appropriate. c. Further assess the patient’s cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families. ANS: C
A health care provider should not assume an understanding of a person’s culture but should ask about cultural beliefs that may impact the health care provided, such as health practices and religious beliefs. Some people may believe that the cure is incomplete unless the body, mind, and spirit are also healed so may seek help from folk or religious healers in addition to biomedical or scientific health care. Members of the Mexican-American culture often seek care of curandero or priest. The nurse should conduct a cultural assessment of the patient to learn about her cultural beliefs that may impact the health care provided, not contact the hospital administrator. The nurse should not arrange for a folk healer before finding out the patient’s beliefs on health care practices and also a Shaman is the typical folk healer for a American Indians. The nurse should not ask the family their preferences, but the patient herself. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 19. A 63-year-old Chinese-American man who recently found out his wife has cancer enters the
hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse’s best course of action? a. The nurse should focus on psychosomatic complaints. b. The nurse should focus on performing a full cardiac assessment.
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c. The nurse should send him home with instructions to contact his physician. d. The nurse should perform both physical and psychosocial assessments. ANS: D
Wide cultural variations exist in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental/psychosocial experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart). However, the nurse should not assume that his physical symptoms are a manifestation of mental/psychosocial experience and should perform both physical and psychosocial assessments. Although Chinese-Americans sometimes convert mental experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart), the nurse should not assume that it is psychosomatic problem. Thus, the nurse should not send the client home with instructions to call his physician or solely focus on either psychosomatic complaints or a physical assessment, but should assess both. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 20. Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which of the
following is a true statement regarding pain? a. Nurses’ attitudes toward their patients’ pain are unrelated to their own experiences with pain. b. Nurses need to recognize that many cultures practice silent suffering as a response to pain. c. A nurse’s area of clinical practice will most likely determine his or her assessment of a patient’s pain. d. A nurse’s years of clinical experience and current position are strong indicators of his or her response to patient pain. ANS: B
Silent suffering is a potential response to pain in many cultures. The nurse’s assessment of pain needs to be embedded in a cultural context. The other responses are not correct. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 21. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding
pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance 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
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In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 22. During a class on religion and spirituality, the nurse is asked to define spirituality. Which
statement by the nurse best describes spirituality? a. “Is a personal search to discover a supreme being.” b. “Is an organized system of beliefs concerning the cause, nature, and purpose of the universe.” c. “Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife.” d. “Focuses on a connection with something bigger than oneself and a belief in transcendence.” ANS: D
Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence. It arises out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. The other definitions reflect the concept of religion. Searching to discover a supreme being; an organized system of beliefs concerning the cause, nature, and purpose of the universe; and believing that each person exists forever in some form all refer to religion rather than spirituality. Spirituality is a broader term focused on a connection with something bigger than oneself and a belief in transcendence. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 23. When caring for children with a different cultural perspective, what should the nurse
recognize may pose a challenge? a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents’ perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their children’s spiritual needs. ANS: A
Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child’s developmental level and the religious climate that exists in the family. The other statements are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
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24. A 30-year-old woman has recently moved to the United States with her husband. They are
living with the woman’s sister until they can get a home of their own. When company arrives to visit with the woman’s sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak “perfect English.” What is this woman likely experiencing? a. Culture shock b. Cultural taboos c. Cultural unfamiliarity d. Culture disorientation ANS: A
Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with the individual’s perceptions and expectations. The other terms are not correct. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 25. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of
the following statements is true about self-treatment? a. “Not recognized as valuable by most health care providers.” b. “Usually ineffective and may delay more effective treatment.” c. “Always less expensive than biomedical alternatives.” d. “Influenced by the accessibility of over-the-counter medicines.” ANS: D
After a symptom is identified, the first effort at treatment is often self-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments such as over-the-counter medications are effective. Self-treatment is not always less expensive. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 26. The nurse is reviewing the hot/cold theory of health and illness. Which statement best
describes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence the humors of the body. b. Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual. d. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body. ANS: D
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The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. The other statements are not correct. The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile; not on supernatural forces influencing them. Herbs, medicines, spiritual connectedness, and social aspects of the individual are not any of the four humors in the hot/cold theory. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 27. When providing culturally competent care, nurses must incorporate cultural assessments into
their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient? a. “Are you of the Christian faith?” b. “Do you want to see a medicine man?” c. “How often do you seek help from medical providers?” d. “What cultural or spiritual beliefs are important to you?” ANS: D
The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 28. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement
illustrates the concept of a cultural taboo? a. Trying prayer before seeking medical help. b. Believing that illness is a punishment of sin. c. Refusing to accept blood products as part of treatment. d. Stating that a child’s birth defect is the result of the parents’ sins. ANS: C
Cultural taboos are practices that are to be avoided, such as receiving blood products, eating pork, and consuming caffeine. The other answers do not reflect cultural taboos. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 29. The nurse should recognize that categories such as ethnicity, gender, and religion illustrate
which concept? a. Family b. Cultures c. Spirituality d. Subcultures ANS: D
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Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups. Ethnicity, gender, and religion are not concepts of family, cultures, or spirituality. Instead they are concepts of subcultures which are groups of people within a larger culture that share differences in ethnicity, religion, education, occupation, age, and gender from the larger culture. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 30. The nurse is reviewing concepts related to one’s heritage and beliefs. Which concept refers to
belief in a divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe? a. Culture b. Religion c. Ethnicity d. Spirituality ANS: B
A belief in a divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe refers to religion. Religion is an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. Culture is a complex phenomenon that includes attitude, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It does not refer to a belief in a divine or superhuman power. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others. Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity 31. When planning a cultural assessment, the nurse should include which component? a. Family history b. Chief complaint c. Medical history d. Health-related beliefs ANS: D
Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient’s history. Family history, chief complaint, and medical history are part of a patient’s history but not part of a cultural assessment. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE
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1. The nurse is asking questions about a patient’s health beliefs. Which questions are
appropriate? (Select all that apply.) a. “What is your definition of health?” b. “Does your family have a history of cancer?” c. “How do you describe illness?” d. “What did your mother do to keep you from getting sick?” e. “Have you ever had any surgeries?” f. “How do you keep yourself healthy?” ANS: A, C, D, F
The questions listed are appropriate questions for an assessment of a patient’s health beliefs and practices. The questions regarding family history and surgeries are part of the patient’s physical history, not the patient’s health beliefs. Questions regarding family history and surgeries are not part of a patient’s health beliefs, but are part of the patient’s physical history. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
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Chapter 03: The Interview Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. The nurse is conducting an interview with a woman who has recently learned that she is
pregnant and who 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, which statement does the nurse know to be most accurate when describing this woman? a. Excited about her pregnancy but nervous about the labor b. Exhibiting verbal and nonverbal behaviors that do 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 negatively respond to her if she states this ANS: B
Communication is all behaviors, conscious and unconscious, verbal and nonverbal. All behaviors have meaning. Her behavior does not imply that she is nervous about labor, upset by her husband, or worried about the nurse’s response. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 2. Receiving is a part of the communication process. Which receiver is most likely to
misinterpret a message sent by a health care professional? a. Well-adjusted adolescent who came in for a sports physical b. Recovering alcoholic who came in for a basic physical examination c. Man who came in with his wife who was just diagnosed with lung cancer d. Man with a hearing impairment who has an interpreter with him who came in for a follow-up blood pressure check ANS: C
In addition to a receiver interpreting a sender’s message based on their past experiences, culture, and self-concept, physical and emotional states also play a role in interpretation. The man whose wife has just been diagnosed with lung cancer may be experiencing emotions that affect his receiving. The receiver attaches meaning determined by his or her experiences, culture, self-concept, and current physical and emotional states. The man whose wife has just been diagnosed with lung cancer may be experiencing emotions that affect his receiving. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 3. Which adjustment in the physical environment should the nurse make to promote the success
of an interview? a. Arrange seating across a desk or table. b. Reduce noise by turning off televisions and radios. c. Reduce the distance between the interviewer and the patient to 2 feet or less. d. Provide dim lighting to make the room cozy and help the patient relax.
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ANS: B
The nurse should secure a quiet environment, thus, should reduce noise by turning off the television, radio, and other unnecessary equipment, because multiple stimuli are confusing. The interviewer and patient should be approximately 4 to 5 feet apart; the room should be well-lit, enabling the interviewer and patient to see each other clearly. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. The interviewer and patient should be approximately 4 to 5 feet apart. Sitting closer than that to a patient, or encroaching on them, can cause anxiety. The room should be well-lit, enabling the interviewer and patient to see each other clearly. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 4. In an interview, the nurse may find it necessary to take notes to aid his or her memory later.
Which statement is true regarding note-taking? a. Note-taking may impede the nurse’s observation of the patient’s nonverbal behaviors. b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. ANS: A
The use of history forms and note-taking may be unavoidable. However, the nurse must be aware that note-taking during the interview has disadvantages, one of which is impeding the nurse’s observations of the patient’s nonverbal behavior. Note-taking often interrupts the patient’s narrative flow, rather than allowing them to keep their own pace. Note-taking can break eye contact and also shift the nurse’s attention away from the patient which can diminish the patient’s sense of importance. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 5. The nurse asks, “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.” Based on this question, the nurse is at which phase of the interview process? a. Summary b. Closing c. Working d. Opening or introduction ANS: D
When gathering a complete history, the nurse should give the reason for the interview during the opening or introduction phase of the interview, not during or at the end of the interview. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance
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6. A woman has just entered the emergency department after being battered by her husband. The
nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? a. “Hello, Nancy, my name is Nurse C.” b. “Mrs. H., my name is Nurse C. How are you?” c. “Hello, Mrs. H., my name is Nurse C. It sure is cold today!” d. “Mrs. H., my name is Nurse C. I’ll need to ask you a few questions about what happened.” ANS: D
The nurse should address the person by using his or her surname as automatic use of the first name is too familiar for most adults and lessens dignity. The nurse should introduce him or herself and give the reason for the interview. Friendly small talk is not needed to build rapport. The nurse should not initially address a patient by their first name as automatic use of the first name is too familiar for most adults and lessens dignity. Statements such as “How are you today” and “It sure is cold out today” are small talk and are not necessary to build rapport. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 7. During an interview, the nurse states, “You mentioned having shortness of breath. Tell me
more about that.” Which verbal skill is used with this statement? a. Reflection b. Facilitation c. Direct question d. Open-ended question ANS: D
Open-ended questions ask for narrative information and give the patient free rein. They state the topic to be discussed but only in general terms, which is what the statement in this question does. The nurse should use open-ended questions to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. Reflection and facilitation refer to the nurse’s (interviewer’s) verbal response of their reactions to the facts or feeling the patient has communicated. Direct questions elicit a one or two word answer such as yes or no. The statement in this question is eliciting more than a yes or no response, so it is not a direct question. Instead the statement in the question is an open-end question allowing the patient free rein on what to say. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 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 hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. “Mr. Y., at your age, surely you have been hospitalized before!” b. “Mr. Y., I just need permission to get your medical records from County Medical.” c. “Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?” d. “Mr. Y., I just need to get some additional information about your past
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hospitalizations. When was the last time you were admitted for chest pain?” ANS: D
The nurse should use direct questions after the person’s opening narrative to fill in any details he or she left out. The nurse also should use direct questions when specific facts are needed, such as when asking about past health problems or during the review of systems. The nurse should not assume that a patient has been hospitalized based on their age and stating such is inappropriate. Getting the patient’s medical records from another facility is not necessary during the interview process. Asking the patient to tell you more about hospitalization in order to complete missing interview data is not necessary; instead, direct questions should be asked when specific facts are needed. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 9. In using verbal responses to assist the patient’s narrative, some responses focus on the
patient’s frame of reference and some focus on the health care provider’s perspective. Which is an example of a verbal response that focuses on the health care provider’s perspective? a. Empathy b. Reflection c. Facilitation d. Confrontation ANS: D
When the health care provider uses the response of confrontation, the frame of reference shifts from the patient’s perspective to the perspective of the health care provider, and the health care provider starts to express his or her own thoughts and feelings. Empathy, reflection, and facilitation responses focus on the patient’s frame of reference. Empathy, reflection, and facilitation responses focus on the patient’s frame of reference. Confrontation focuses on the health care provider’s frame of reference and involves the health care provider expressing his or her own thoughts and feelings. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity 10. When taking a history from a newly admitted patient, the nurse notices that he often pauses
and expectantly looks at the nurse. What would be the nurse’s best response to this behavior? a. Lean forward slightly and making eye contact ask “Is there anything else?” b. Smile at him and say, “Don’t worry about all of this. I’m sure we can get to the bottom of your symptoms.” c. Lean back in the chair and ask, “You are looking at me kind of funny; 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.” ANS: A
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Typically patients will answer questions with short answers and then pause and look to the health care provider for direction on whether to continue. In this case, the health care provider should lean forward slightly, make eye contact, and look interested and if the patient does not continue, then ask them to tell you more or ask if there anything else. The other responses are not conducive to ideal communication. Leaning back in the chair or standing up indicates disinterest or closure and making statements such as “Don’t worry about all of this. I’m sure we can get to the bottom of your symptoms;” “You are looking at me kind of funny; there isn’t anything wrong, is there?”; or “I can see that this interview is uncomfortable for you. We can continue it another time” dismiss the patient’s feelings or are confrontational and are not conducive to ideal communication. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 11. A woman is discussing the problems she is having with her 2-year-old son. She says, “He
won’t go to sleep at night, and during the day he has several fits. I get so upset when that happens.” Which is the best response by the nurse to gain a better understanding of the problem? 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
The nurse should use clarification when the person’s word choice is ambiguous or confusing (e.g., “Tell me what you mean by fits.”). Clarification is also used to summarize the person’s words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track. Telling the woman “Go on, I’m listening”; “Yes, it can be upsetting when a child has a fit”; or “Don’t be upset when he has a fit; every 2 year old has fits” does not allow the nurse to clarify what the woman means by the term “fits” which is necessary to gain a better understanding of the problem. The nurse should use clarification when the person’s word choice is ambiguous or confusing (e.g., “Tell me what you mean by fits.”). Clarification is also used to summarize the person’s words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 12. A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child 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 these 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 care for a child all alone.” d. “I would be angry, too; raising a child alone is no picnic.” ANS: C
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An empathetic response recognizes the feeling and puts it into words. It names the feeling, allows its expression, and strengthens rapport. Some empathetic responses are, “This must be very hard for you,” “I understand,” or simply placing your hand on the person’s arm. Simply reflecting the person’s words or agreeing with the person is not an empathetic response. Simply reflecting the person’s words by saying “You feel alone” or “You can’t believe he left you alone”, or agreeing with the person by saying “I would be angry, too; raising a child alone is no picnic” are not empathetic responses. They do not name the feeling, allow its expression or strengthen rapport. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 13. The nurse has used interpretation regarding a patient’s statement or actions. What should the
nurse do after using this technique? a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurse’s conclusion on the basis of the patient’s nonverbal response. ANS: B
The nurse’s, or interviewer’s, interpretation of a patient’s statement is based on their inference or conclusion. The nurse risks making the wrong inference. Pausing after an interpretation allows time for the patient to correct it if it is wrong. Even if the inference is correct, interpretation helps prompt further discussion of the topic. Apologizing after interpreting a patient’s statement should not be necessary as the nurse should have stated that the interpretation is just his or her own inference from what the patient said and not a conclusion and is open for clarification. Continuing the interview as if nothing has happened or immediately restating the nurse’s conclusion based on the patient’s nonverbal response does not allow time for the patient to confirm or correct the inference. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 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, but I just can’t seem to leave him.” Using interpretation, which would be the best response by the nurse? a. “You are going to leave him?” b. “If you are afraid for your children, then 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
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The statement “It sounds as if you might be afraid of how your husband will respond” is linking events, making associations, and implying cause, which are what occur in interpretation. Interpretation also recognizes feelings and helps the person understand his or her own feelings in relation to the verbal message. The other statements do not reflect interpretation. The statement “You are going to leave him?” is a direct question, not an interpretation. The statements “If you are afraid for your children, then why can’t you leave?” and “It sounds as though you have made your decision. I think it is a good one” do not recognize the person’s feelings or link events, make associations, or imply cause. In addition, in the latter statement the nurse is providing his or her opinion which is inappropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 15. A pregnant woman states, “I just know labor will be so painful that I won’t be able to stand it.
I know it sounds awful, but I really dread going into labor.” The nurse responds by stating, “Oh, don’t worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.” Which statement is true regarding the nurse’s response? a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication. ANS: B
By saying “Oh, don’t worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain” the nurse is providing false assurance or reassurance. This may give the nurse a false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually trivializes her anxiety, and effectively denies any further talk of it, thus, closing off communication. The nurse’s statement, “Oh, don’t worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain” is not therapeutic because it trivializes the patient’s anxiety about pain, and effectively denies any further talk of it, thus, closing off communication. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 16. During a visit to the clinic, a patient states, “The doctor just told me he thought I ought to stop
smoking. He doesn’t understand how hard I’ve tried. I just don’t know the best way to do it. What should I do?” What is the most appropriate response by the nurse? a. “I’d quit if I were you. The doctor really knows what he is talking about.” b. “Would you like some information about the different ways a person can quit smoking?” c. “Stopping your dependence on cigarettes can be very difficult. I understand how you feel.” d. “Why are you confused? Didn’t the doctor give you the information about the
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smoking cessation program we offer?” ANS: B
Clarification should be used when the person’s word choice is ambiguous or confusing. Clarification is also used to summarize the person’s words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track. The other responses give unwanted advice or do not offer a helpful response. Saying “I’d quit if I were you. The doctor really knows what he is talking about”, “Stopping your dependence on cigarettes can be very difficult. I understand how you feel”, or “Why are you confused? Didn’t the doctor give you the information about the smoking cessation program we offer?” either provide unwanted advice or do not offer a helpful response. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 17. As the nurse enters a patient’s room, the nurse finds the patient crying. The patient states that
she has just found out that the lump in her breast is cancer and says, “I’m so afraid of, um, you know.” Which would be the most therapeutic response by the nurse when said in a gentle manner? a. “You’re afraid you might lose your breast?” b. “No, I’m not sure what you are talking about.” c. “I’ll wait here until you get yourself under control, and then we can talk.” d. “I can see that you are very upset. Perhaps we should discuss this later.” ANS: A
This statement demonstrates reflection. Reflection echoes the patient’s words, repeating part of what the person has just said, and it also can help express the feelings behind a person’s words. Stating “No, I’m not sure what you are talking about” is not the most therapeutic response as it does not acknowledge the patient’s feelings. Stating “I’ll wait here until you get yourself under control, and then we can talk” or “I can see that you are very upset. Perhaps we should discuss this later” are not therapeutic as they are not addressing the patient’s feelings and concerns at the time. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 18. A nurse is taking complete health histories on all of the patients attending a wellness
workshop. On the history form, one of the written questions asks, “You don’t smoke, drink, or take drugs, do you?” This is an example of what type of question? a. Talking too much b. Using confrontation c. Using biased or leading questions d. Using blunt language to deal with distasteful topics ANS: C
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This question is an example of using leading or biased questions. Asking, “You don’t smoke, do you?” implies that one answer is better than another. If the person wants to please someone, then he or she is either forced to answer in a way that corresponds to his or her implied values or is made to feel guilty when admitting the other answer. Talking too much, using confrontation, or using blunt language to deal with distasteful topics are not types of questions. Asking, “You don’t smoke, do you?” is a biased or leading question because it implies that one answer is better than another. If the person wants to please someone, then he or she is either forced to answer in a way that corresponds to his or her implied values or is made to feel guilty when admitting the other answer. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 19. When observing a patient’s verbal and nonverbal communication, the nurse notices a
discrepancy. What action should the nurse take in this situation? a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patient’s verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patient’s nonverbal behaviors, because these are often more reflective of a patient’s true feelings. ANS: D
When nonverbal and verbal messages are congruent, the verbal message is reinforced. When they are incongruent, as in this case, the nonverbal message tends to be the true one because it is under less conscious control. The other statements are not true. When nonverbal and verbal messages are incongruent, as in this case, the nonverbal message tends to be the true one because it is under less conscious control. Thus, asking someone who knows the patient well to help interpret this discrepancy; focusing on the patient’s verbal message, and trying to ignore the nonverbal behaviors; and trying to integrate the verbal and nonverbal messages and then interpret them as an average are inappropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 20. During an interview, a parent of a hospitalized child is sitting in a recliner with his legs
extended and his arms at his sides. As the interviewer begins to discuss his son’s treatment, however, he suddenly changes positions and crosses his arms against his chest and crosses his legs. What does this change in posture suggest? a. Simply changing positions b. More comfortable in this position c. Tired and needs a break from the interview d. Uncomfortable talking about his son’s treatment ANS: D
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The parent was in an open position, one in which there is extension of large muscle groups which shows relaxation, physical comfort, and a willingness to share information. However, he moved into a closed position, in which the arms and legs are crossed. This closed position tends to look defensive and anxious. If a person in a relaxed position suddenly tenses, then this change in posture suggests possible discomfort with the new topic. The parent’s position should be noted. If a person in an opened, relaxed position (legs and arms extended) suddenly tenses and moves to a closed position (arms and legs crossed)then this change in posture suggests possible discomfort with the new topic and is more than just changing positions to get comfortable or needing a break. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 21. A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the
beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to “warm up” and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view. ANS: B
Although most of the communication is with the parent, the nurse should not completely ignore the child. Making contact will help ease the toddler later during the physical examination. The nurse should begin by asking about the toys the child is playing with or about a special doll or teddy bear brought from home. “Does your doll have a name?” or “What can your truck do?” Stoop down to meet the child at his or her eye level. Although making contact with the toddler will help ease him/her later during the physical examination, the nurse should begin by asking about the toys the child is playing with or about a special doll or teddy bear brought from home before touching or tickling them. Children are frightened by quick or grandiose gestures. The nurse should not completely ignore the child as making contact will help ease the toddler later during the physical examination. The nurse should not ask the mother to leave during the examination as that will cause anxiety for the toddler. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 22. During an examination of a preschool child, the nurse will need to take her blood pressure.
What might the nurse do to try to gain the child’s full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are. ANS: D
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Preschoolers’ communication is direct, concrete, literal, and set in the present. Therefore, health care providers should use short, simple sentences with a concrete explanation for any unfamiliar equipment that will be used on the child. Preschoolers are animistic; they imagine inanimate objects can come alive and have human characteristics. Thus a blood pressure cuff can wake up and bite or pinch. Preschoolers are animistic; they imagine inanimate objects can come alive and have human characteristics. Thus, the nurse should not say that the blood pressure cuff will give her arm a hug, that it is asleep, or that give it a name as those are humanistic characteristics and the blood cuff could wake up or come alive. Therefore, health care providers should use short, simple sentences with a concrete explanation for any unfamiliar equipment that will be used on the child. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 23. A 16-year-old boy has just been admitted to the hospital for overnight observation after being
in an automobile accident. What is the best approach for the nurse to use to communicate with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up. ANS: B
The guidelines for communicating with adolescents are simple. The first consideration is one’s attitude, which must be one of respect. Second, communication must be totally honest. An adolescent’s intuition is highly tuned and can detect phoniness or the withholding of information. Always tell him or her the truth. The nurse should avoid periods of silence when communicating with adolescents as silence can be seen as threatening to them. The nurse should not tell an adolescent that everything will be confidential as that is not true. Something need to be reported by law or for the adolescent’s well-being. While it is helpful to understand the jargon or slang used by adolescents, the nurse should not use that language as they are not part of the adolescent’s peer group and won’t be accepted as a peer. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 24. A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the
interview may take longer than interviews with younger people. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged people lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said. ANS: A
The interview usually takes longer with older adults because they have a longer story to tell. It is not necessarily true that all older adults are lonely, have lost mental abilities, or are hard of hearing. Not all older adults are lonely, have lost mental abilities, or are hard of hearing. Instead, the interview usually takes longer because older adults have a longer story to tell.
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DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 25. The nurse is interviewing a male patient who has a hearing impairment and came in because
of a cold. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read. ANS: A
The nurse should ask a person with a hearing impairment the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him squarely and have good lighting on the nurse’s face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and supplement his or her voice with appropriate hand gestures or pantomime. The nurse does not need to avoid facial expressions or hand gestures as these nonverbal cues are important adjuncts and supplement his or her voice. The nurse should find out the person’s preferred communication method before arranging for a sign language interpreter. The nurse should not speak too loudly because that actually distorts the reception of hearing aids and exaggerated lip and facial movements when talking distorts the words. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 26. During a prenatal check, a patient begins to cry as the nurse asks her about previous
pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. Which is the best response by the nurse? a. “I’m so sorry for making you cry!” b. “I can see that you are sad remembering this. It is all right to cry.” c. “Why don’t I step out for a few minutes until you’re feeling better?” d. “I can see that you feel sad about this; why don’t we talk about something else?” ANS: B
A beginning examiner may feel uncomfortable when a patient starts crying. When the nurse says something that “makes the person cry,” the nurse should not think he or she has hurt the person. The nurse has simply hit on an important topic; therefore, the nurse should allow the person to cry and to express his or her feelings fully. The nurse can offer a tissue and wait until the crying subsides to talk. When the nurse says something that “makes the person cry,” the nurse should not think he or she has hurt the person. The nurse has simply hit on an important topic. The nurse should not apologize, leave the person alone, or change the topic, but rather allow the person to cry and express his or her feelings fully. The nurse can offer a tissue and wait until the crying subsides to talk. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
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27. The nurse is performing a health interview on a patient who has a language barrier, and no
interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. “Do you take medicine?” b. “Are you in any discomfort?” c. “Do you have nausea and vomiting?” d. “You have been following your doctor’s orders, haven’t you?” ANS: A
In a situation during which a language barrier exists and no interpreter is available, simple words should be used, such as “Do you take medicine” or the word pain rather than discomfort. The use of medical jargon, contractions, and pronouns should be avoided. Nouns should be repeatedly used, and one topic at a time should be discussed. Simple words like pain should be used rather than words like discomfort, nausea, and vomiting. The use of contractions such as “haven’t” as well as medical jargon and pronouns should be avoided. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 28. A man arrives at the clinic for his annual wellness physical. He is experiencing no acute
health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. “How is your family?” b. “How is your job?” c. “Tell me about your hypertension.” d. “How has your health been since your last visit?” ANS: D
Open-ended questions are used for gathering narrative information. This type of questioning should be used to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. “How is your family” and “How is your job” are small talk and do not provide any information on the patient’s health. The nurse should not begin with asking about the patient’s hypertension but should begin the interview with a more general open-ended question. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 29. The nurse says to a patient, “I know it may be hard, but you should do what the doctor ordered
because she is the expert in this field.” Which statement is correct about the nurse’s comment? a. It is inappropriate because it shows the nurse’s bias. b. It is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times. ANS: C
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Using authority responses promotes dependency and inferiority. Avoiding the use of authority is best. Although the health care provider and patient do not have equal professional knowledge, both have equally worthy roles in the health process. The other statements are not correct. The comment “I know it may be hard, but you should do what the doctor ordered because she is the expert in this field” by the nurse does not show bias. In addition, not all members in the health care field are considered experts and using authority should be avoided. Although the health care professional may have more professional knowledge than the patient, both have equally important roles since the patient must make the final decision about his or her health. Using authority responses promotes dependency and inferiority and avoiding the use of authority is best. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 30. A female patient does not speak English well, and the nurse needs to choose an interpreter.
Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department ANS: A
Whenever possible, the nurse should use a trained interpreter. This person knows interpreting techniques, has a health care background, and understands patients’ rights. A trained interpreter is also knowledgeable about cultural beliefs and health practices. He or she can help you bridge the cultural gap and advise you concerning the cultural appropriateness of your recommendations. Although it is tempting to ask ad hoc interpreters such as a male or female family member, or volunteer college student from the foreign language studies department, there are several disadvantages to that. Using an ad hoc interpreter can violate the patient’s confidentiality and they often are not familiar with medical terminology, hospital or clinical procedures, or medical ethics. Having a relative interpret can add stress to an already stressful situation and may disrupt family relationships. In addition, in some cultures full disclosures of a diagnosis such as cancer are taboo, so an ad hoc interpreter may edit the diagnosis or not fully disclose the information. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 31. During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a
regular basis. The nurse asks, “Why haven’t you taken your insulin?” Which statement is an appropriate evaluation of this situation? a. This question may place the patient on the defensive. b. This question is an effective way to search for information. c. Discussing his behavior with his wife would have been better. d. A direct question is the best way to discover the reasons for his behavior. ANS: A
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This is a “why” question and the adult’s use of “why” questions usually implies blame and condemnation and places the person on the defensive. The other statements are not correct. The question, “Why haven’t you taken your insulin?” is not an effective way to search for information as it often puts the person on the defensive. Discussing his behavior with his wife could be a breach in confidentiality and asking a direct question is not the best way to discover reasons for his behavior as they elicit yes or no answers. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 32. The nurse is nearing the end of an interview. Which statement is appropriate at this time? a. “Did we forget something?” b. “Is there anything else you would like to mention?” c. “I need to go on to the next patient. I’ll be back.” d. “While I’m here, let’s talk about your upcoming surgery.” ANS: B
This question offers the person a final opportunity for self-expression. No new topic should be introduced. The other questions are not appropriate. Asking the person “Did we forget anything?” is a direct question eliciting a yes or no response and does not provide an opportunity for self-expression or additional information. Stating that you need to go to another patient and will be back or that you want to talk about the person’s upcoming surgery while you’re there is not appropriate as you are not allowing the patient to express anything further and are introducing a new topic. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 33. What data should the nurse collect during the interview portion of a health assessment. a. Physical b. Historical c. Objective d. Subjective ANS: D
The interview is the first, and really the most important, part of data collection. During the interview, the nurse collects subjective data; that is, what the person says about him or herself. Physical data is gathered in the physical examination portion of a health assessment. Historical data is gathered from the medical records. Objective data is what the nurse observes, this typically occurs during the physical examination, not the interview. During the interview, the nurse collects subjective data; that is, what the person says about him or herself. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity 34. During an interview, the nurse would expect that most of the interview will take place at what
distance? a. Intimate zone b. Personal distance c. Social distance d. Public distance
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ANS: C
Social distance, 4 to 12 feet, is usually the distance category for most of the interview. Public distance, over 12 feet, is too much distance; the intimate zone is inappropriate, and the personal distance will be used for the physical assessment. The intimate, personal public zones are inappropriate to conduct an interview. The intimate zone (1–1 ft.) is usually uncomfortable for people. The personal zone (1 to 4 ft.) will be used for the physical assessment. The public zone (12+ ft.) is too far away to allow for confidentiality of information or to express interest in someone. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 35. A female nurse is interviewing a male patient who is near the same age as the nurse. During
the interview, the patient makes an overtly sexual comment. Which is the best response by the nurse? a. “Stop that immediately!” b. “Oh, you are too funny. Let’s keep going with the interview.” c. “Do you really think I would be interested?” d. “It makes me uncomfortable when you talk that way. Please stop.” ANS: D
The nurse’s response must make it clear that she is a health professional who can best care for the person by maintaining a professional relationship. At the same time, the nurse should communicate that he or she accepts the person and understands the person’s need to be self-assertive but that sexual advances cannot be tolerated. Saying “Stop that immediately,” “Oh, you are too funny. Let’s keep going with the interview,” or “Do you really think I would be interested?” do not acknowledge how the patient’s actions make the nurse feel and do not make it clear that they must maintain a professional relationship in order to best care for the patient. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse is conducting an interview. Which of these statements is true regarding open-ended
questions? (Select all that apply.) a. Elicit hard facts. b. Allow for self-expression. c. Build and enhance rapport. d. Call for short one- to two-word answers. e. Are used when narrative information is needed. ANS: B, C, E
Open-ended questions allow for self-expression, build and enhance rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions. Open-ended questions do not elicit hard facts or one- or two-word answers but allow for self-expression and narrative information.
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DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 2. The nurse is conducting an interview in an outpatient clinic and is using a computer to record
data. Which are the best uses of the computer in this situation? (Select all that apply.) a. Collect the patient’s data in a direct, face-to-face manner. b. Enter all the data as the patient states them. c. Ask the patient to wait as the nurse enters the data. d. Type the data into the computer after the narrative is fully explored. e. Allow the patient to see the monitor during typing. ANS: A, D, E
The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient’s narrative story in a direct, face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it. The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient’s narrative story in a direct, face-to-face manner. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance
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Chapter 04: The Complete Health History Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. The nurse is preparing to conduct a health history. Which of these statements best describes
the purpose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patient’s biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patient’s past and current health ANS: D
The purpose of the health history is to collect subjective data—what the person says about him or herself. The other options are not correct. Although conducting a health history allows the nurse an opportunity for interaction with the patient and a method for obtaining a patient’s biographic data, the purpose of the health history is to collect subjective data—what the person says about him or herself. The other options are not correct. The documentation of normal and abnormal findings of a physical assessment is part of the physical examination. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 2. When the nurse is evaluating the reliability of a patient’s responses, which of these statements
would be correct? a. Patient has a history of drug abuse and therefore is not reliable. b. Patient provided consistent information and therefore is reliable. c. Patient smiled throughout interview and therefore is assumed reliable. d. Patient would not answer questions concerning stress and therefore is not reliable. ANS: B
A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black
stools” for the last 24 hours. How would the nurse best document his reason for seeking care? a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours. ANS: D
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The reason for seeking care is a brief spontaneous statement in the person’s own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the person’s exact words. Options A, B, and C do not contain the patient’s exact words in quotations regarding the reason they are seeking care. The reason for seeking care is a brief spontaneous statement in the person’s own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the person’s exact words. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the
nurse’s best response? a. “Can you point to where it hurts?” b. “What have you had to eat in the last 24 hours?” c. “Have you ever had any surgeries on your abdomen?” d. “We’ll talk more about that later in the interview.” ANS: A
As a person talks, the nurse should not come to any conclusions but should collect all data first of a symptom. A final summary of any symptom the person has should include the specific location, so having the patient point to where the pain is located is appropriate. There are eight critical characteristics to be included in the summary of any symptom: “Location, Character or Quality, Quantity or Severity, Timing, Setting, Aggravating or Relieving Factors, Associated Factors, and Patient’s Perception. Options B, C, and D do not collect the necessary data to make a summary of the symptom. A final summary of any symptom the person has should include eight critical characteristics: “Location, Character or Quality, Quantity or Severity, Timing, Setting, Aggravating or Relieving Factors, Associated Factors, and Patient’s Perception.” DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which
response by the nurse would be appropriate? a. “How does your family react to your pain?” b. “The pain must be terrible. You probably pinched a nerve.” c. “I’ve had back pain myself, and it can be excruciating.” d. “How would you say the pain affects your ability to do your daily activities?” ANS: D
The symptom of pain is difficult to quantify because of individual interpretation. It is important to find out the meaning of the pain to the person by asking how it affects daily activities. The nurse needs to find out the patient’s perception or meaning of the pain, rather than how the family reacts to it. The nurse should avoid the use of adjectives when discussing the person’s pain, should not give his or her opinion of the cause, or focus on their own experience with pain. Instead, the nurse should ask the patient how the pain affects his or her daily activities. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance
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6. In recording the childhood illnesses of a patient who denies having had any, which note by the
nurse would be most accurate? a. Patient denies usual childhood illnesses. b. Patient states he was a “very healthy” child. c. Patient states his sister had measles, but he didn’t. d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. ANS: D
This is the most specific statement about childhood illnesses. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles). When recording information about childhood illnesses, the nurse should avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles). Recording the patient was a very healthy child does not confirm or deny specific childhood illnesses and recording the patient stated his sister had measles but he didn’t does not address the other childhood illnesses. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 7. A female patient tells the nurse that she has had six pregnancies, with four live births at term
and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. P-6, B-4, (S)Ab-2 b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant 6 times. ANS: B
Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (miscarriages or abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion. Option A does not use approved medical abbreviations and does not include the number of living children. Options C and D do not include all the pertinent data of the person’s obstetric history. Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (miscarriages or abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. A patient tells the nurse that he is allergic to penicillin. What is the best response by the
nurse?
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a. b. c. d.
“Are you allergic to any other drugs?” “How often have you received penicillin?” “Describe what happens to you when you take penicillin.” “I’ll write your allergy on your chart so you won’t receive any penicillin.”
ANS: C
When a person states he or she has an allergy, the nurse should note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). Before asking the patient about other allergies, the nurse should find out the patient’s reaction to penicillin. Asking how often the patient has received penicillin is not necessary. Before documenting that a patient is allergic to a medication, the nurse should find out the reaction to it to determine if it is a true allergy or an unpleasant side effect. Both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing) should be recorded. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is taking a family history. Which specific disease or problem should be included in
the assessment? a. Emphysema b. Head trauma c. Mental illness d. Fractured bones ANS: C
When reviewing the family history, the nurse should ask specifically about any history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis (TB). Although a family history of emphysema and fractured bones may be good to know, they are not one of the specific diseases that should be specifically asked. A family history of head trauma is not a familial or hereditary characteristic and is not necessary to include in the assessment. Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis should be asked. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Health Promotion and Maintenance 10. What does the review of systems provide the nurse? a. Physical findings r/t each system b. Information regarding health promotion practices c. An opportunity to teach the patient medical terms d. Information necessary for the nurse to diagnose the patient’s medical problem ANS: B
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The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double-check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices. The review of systems does not provide the physical findings of each body system, an opportunity to teach the patient medical terms, or the information necessary for the nurse to diagnose the patient’s medical problem. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Health Promotion and Maintenance 11. What information obtained by the nurse regarding a patient’s skin should the nurse record in
the patient’s health history? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm. ANS: C
The purpose of the health history is to collect subjective data, or what the person says about him or herself, so should be limited to patient statements that the person says were or were not present. Skin appears dry, no lesions are obvious, and lesions noted on the lateral aspect of the right arm are all objective data, or things that nurse observed. The purpose of the health history is to collect subjective data, or what the person says about him or herself, so should be limited to patient statements that the person says were or were not present. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health
promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. “Do you perform testicular self-examinations?” b. “Have you ever noticed any pain in your testicles?” c. “Have you had any problems with passing urine?” d. “Do you have any history of sexually transmitted infections?” ANS: A
Health promotion refers to activities that promote a person’s health. For a man that includes the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues. Asking a male patient if they have ever noticed any pain in their testicles, problems with passing urine, or a history of sexually transmitted infections are questions asking about possible disease or illness issues rather than health promotion. Health promotion refers to activities that promote a person’s health. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 13. Which of these responses might the nurse expect during a functional assessment of a patient
whose leg is in a cast? a. “I broke my right leg in a car accident 2 weeks ago.” b. “The pain is decreasing, but I still need to take acetaminophen.”
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c. “I check the color of my toes every evening just like I was taught.” d. “I’m able to transfer myself from the wheelchair to the bed without help.” ANS: D
Functional assessment measures a person’s self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues. Statements such as “I broke my right leg in a car accident 2 weeks ago,” “the pain is decreasing, but I still need to take acetaminophen,” or “I check the color of my toes every evening just like I was taught” are statements concerning health or illness issues and not a person’s self-care or functional ability. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband
and mother both died in the past year. Which response by the nurse is most appropriate? a. “This has been a difficult year for you.” b. “I don’t know how anyone could handle that much stress in 1 year!” c. “What did you do to cope with the loss of both your husband and mother?” d. “That is a lot of stress; now let’s go on to the next section of your history.” ANS: C
Questions about coping and stress management include questions regarding the kinds of stresses in one’s life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful. Options A, B, and D do not assess the person’s methods to cope or alleviate their stress. When asking questions about coping and stress, the nurse should ask regarding the kinds of stresses in one’s life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse
needs to know. What is the reason for needing this information? a. This information is necessary to determine the patient’s reliability. b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless a drinking problem is obvious. ANS: B
Alcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important. The other options are not correct. Determining a person’s alcohol use is important information whether a drinking problem is obvious or not. The reason for needing information about a person’s alcohol use is not to determine their reliability or for the nurse to teach the patient about the dangers of alcohol use. Instead the reason is that alcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important.
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DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What
would be an appropriate response by the nurse? a. “Maybe she is just teething.” b. “I will check her ear for an ear infection.” c. “Are you sure she is really having pain?” d. “Describe what she is doing to indicate she is having pain.” ANS: D
With a very young child, the parent is asked, “How do you know the child is in pain?” A young child pulling at his or her ears should alert parents to the child’s ear pain. Statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 17. During an assessment of a patient’s family history, the nurse constructs a genogram. Which
statement best describes a genogram? a. List of diseases present in a person’s near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patient’s family members up to five generations back d. Description of the health of a person’s children and grandchildren ANS: B
A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). The other options do not describe a genogram. Although identifying the illnesses of relatives on a genogram is important, the listing of the diseases of near relatives is not part of the genogram. A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings); it does not have to be five generations and they are the person’s preceding generations, not generations after them. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 18. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which
information should the nurse collect before this procedure? a. Child’s birth weight b. Age at which he crawled c. Whether the child has had the measles d. Child’s reactions to previous hospitalizations ANS: D
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How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure. The child’s weight at birth, age at which he crawled, or whether or not had the measles is not information needed for the upcoming surgery. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 19. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination,
the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What should the nurse recommend? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21. d. A recommendation cannot be made until the physician is consulted. ANS: B
Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics (2018) recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 20. In obtaining a review of systems on a “healthy” 7-year-old girl, what should the health care
provider be sure to include? a. Last glaucoma examination b. Frequency of breast self-examinations c. Date of her last electrocardiogram d. Limitations r/t her involvement in sports activities ANS: D
When completing a review of the cardiovascular system for a child the health care provider should ask whether there are any congenital heart defects, history of murmurs, or cyanosis as well as if any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age. The date of the last glaucoma examination, frequency of breast self-examinations, and date of last electrocardiogram are not appropriate questions for a review of systems for a “healthy” 7-year-old. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 21. When the nurse asks for a description of who lives with a child, the method of discipline, and
the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care ANS: C
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Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care. Questions about who lives with a child, the method of discipline, and the support system of the child are not part of the family history, review of system, or reason for seeking care. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care. Questions about who lives with a child, the method of discipline, and the support system of the child are questions about the home environment which is part of the functional assessment. Functional assessment includes interpersonal relationships and home environment. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 22. The nurse is performing a functional assessment on an 82-year-old patient who recently had a
stroke. Which of these questions would be most important to ask? a. “Do you wear glasses?” b. “Are you able to dress yourself?” c. “Do you have any thyroid problems?” d. “How many times a day do you have a bowel movement?” ANS: B
Whether a person is able to dress himself or herself assesses his/her ability to perform an activity of daily living. A functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that he/she can or cannot do. The other responses do not relate to functional assessment. Asking whether a patient wears glasses, has any thyroid problems, and how many bowel movements he or she has each day are not part of a functional assessment. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 23. The nurse is preparing to do a functional assessment. Which statement best describes the
purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities. ANS: D
The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment. The functional assessment measures how a person manages day-to-day activities. Options A, B, and C do not reflect the purpose of a functional assessment. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Health Promotion and Maintenance
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24. The nurse is asking a patient for his reason for seeking care and asks about the signs and
symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100° F ANS: A
A symptom is a subjective sensation (e.g., chest pain) that a person feels from a disorder. A sign is an objective abnormality that the examiner can detect on physical examination or in laboratory reports, as illustrated by the other responses. Clammy skin, serum potassium level at 4.2 mEq/L, and body temperature of 100° F are objective data (something that the examiner can detect on physical examination or in laboratory reports). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 25. A patient is describing his symptoms to the nurse. Which of these statements reflects a
description of the setting of his symptoms? a. “It is a sharp, burning pain in my stomach.” b. “I also have the sweats and nausea when I feel this pain.” c. “I think this pain is telling me that something bad is wrong with me.” d. “This pain happens every time I sit down to use the computer.” ANS: D
The setting describes where the person is or what the person is doing when the symptom starts. Describing the pain as “sharp and burning” reflects the character or quality of the pain; stating that the pain is “telling” the patient that something bad is wrong with him reflects the patient’s perception of the pain; and describing the “sweats and nausea” reflects associated factors that occur with the pain. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 26. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the
questions. What could this be indicating? a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance-abuse assessment. ANS: D
The CAGE test is known as the “cut down, annoyed, guilty, and eye-opener” test. If a person answers “yes” to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance-abuse assessment. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
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27. The nurse is incorporating a person’s spiritual values into the health history. Which of these
questions illustrates the “community” portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. “Do you believe in God?” b. “Are you a part of any religious or spiritual congregation?” c. “Do you consider yourself to be a religious or spiritual person?” d. “How does your religious faith influence the way you think about your health?” ANS: B
The “community” is assessed when the nurse asks whether a person is part of a religious or spiritual community or congregation. The other areas assessed are faith, influence, and addressing any religious or spiritual issues or concerns. Asking whether a person believes in God or if he/she considers himself or herself to be religious or spiritual is assessing his/her faith. Asking how his/her religious faith influences the way he/she thinks about his/her health is assessing the influence. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 28. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents
have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. “It would help to interview the three of you together.” b. “While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?” c. “Please stay during the interview; you can answer for her if she does not know the answer.” d. “While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?” ANS: B
The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires. Options A, C, and D are inappropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 29. The nurse is assessing a new patient who has recently immigrated to the United States. Which
question is appropriate to add to the health history? a. “Why did you come to the United States?” b. “When did you come to the United States and from what country?” c. “What made you leave your native country?” d. “Are you planning to return to your home?” ANS: B
Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions. When a patient is a new immigrant several biographic questions should be added to the health history. Why the person came to the United States, what made him/her leave his/her native country, and when he/she is planning to return are not necessary and do not provide any biographic data.
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DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the
critical characteristics of symptoms that should be assessed? (Select all that apply.) a. “Where is the headache pain?” b. “Did you have these headaches as a child?” c. “On a scale of 1 to 10, how bad is the pain?” d. “How often do the headaches occur?” e. “What makes the headaches feel better?” f. “Do you have any family history of headaches?” ANS: A, C, D, E
The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed: (1) P: provocative or palliative; (2) Q: quality or quantity; (3) R: region or radiation; (4) S: severity scale; (5) T: timing; and (6) U: understand the patient’s perception. Asking, “Where is the pain?” reflects “region.” Asking the patient to rate the pain on a 1 to 10 scale reflects “severity.” Asking “How often…” reflects “timing.” Asking what makes the pain better reflects “provocative.” The other options reflect health history and family history. Asking the patient if he/she had these headaches as a child or if there is any family history of headaches are not critical characteristics of a symptom that need to be assessed. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance 2. The nurse is conducting a developmental history on a 5-year-old child. Which questions are
appropriate to ask the parents for this part of the assessment? (Select all that apply.) a. “Can he tell time?” b. “Does he have any food allergies?” c. “Is he able to tie his shoelaces?” d. “Does he take a children’s vitamin?” e. “How much junk food does your child eat?” f. “How many teeth has he lost, and when did he lose them?” ANS: A, C, F
Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history. Questions for a developmental assessment include questions about tooth loss, ability to tell time, and ability to tie shoelaces. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance
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Chapter 05: Mental Status Assessment Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. During an examination, the nurse can assess mental status by which activity? a. Examining the patient’s electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patient’s response to a specific set of questions ANS: C
Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects. Mental status cannot be directly scrutinized through tests such as an electroencephalogram, intelligence quotient (IQ) test, or responses to questions. Instead, the functioning of mental status is inferred through an assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 2. The nurse is assessing the mental status of a child. Which statement about children and mental
status is true? a. All aspects of mental status in children are interdependent. b. Children are highly labile and unstable until the age of 2 years. c. A child’s mental status is impossible to assess until the child develops the ability to concentrate. d. Children’s mental status is largely a function of their parents’ level of functioning until the age of 7 years. ANS: A
It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. The other statements are not true. Options B, C, and D are all false statements. It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 3. The nurse is assessing a 75-year-old man. What should the nurse expect when performing the
mental status portion of the assessment? a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should
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not have declined. d. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge. ANS: C
The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 4. When assessing aging adults, what is one of the first things the nurse should assess before
making judgments about the aging person’s mental status? a. Presence of phobias b. General intelligence c. Sensory-perceptive abilities d. Presence of irrational thinking patterns ANS: C
Presence of phobias, general intelligence, and presence of irrational thinking patterns are not one of the first things a nurse should assess before making a judgment about an aging person’s mental status. Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produce frustration, suspicion, and social isolation and make the person appear confused. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 5. The nurse is preparing to conduct a mental status examination. Which statement is true
regarding the mental status examination? a. A patient’s family is the best resource for information about the patient’s coping skills. b. Gathering mental status information during the health history interview is usually sufficient. c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient’s level of functioning, performing a complete mental status examination is usually necessary. ANS: B
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview. A patient’s family is not the best resource for information about the patient’s coping skills. The nurse can gain ample data to assess mental health and coping skills during the health history with the mental health examination integrated into it.
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DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 6. A woman brings her husband to the clinic for an examination. She is particularly worried
because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. Reassure his wife that memory loss after a physical shock is normal and will soon subside. ANS: A
Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 7. The nurse is conducting a patient interview. Which statement made by the patient should the
nurse more fully explore to assess the mental status during the interview? a. “I sleep like a baby.” b. “I have no health problems.” c. “I never did too good in school.” d. “I am not currently taking any medications.” ANS: C
In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patient’s normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits. A patient stating that he/she sleeps like a baby, has no health problems, or is currently not taking any medications are not r/t the patient’s mental status. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 8. A patient is admitted to the unit after an automobile accident. The nurse begins the mental
status examination and finds that the patient has dysarthric speech and is lethargic. How should the nurse proceed? a. Defer the rest of the mental status examination. b. Skip the language portion of the examination and proceed onto assessing mood and affect. c. Conduct an in-depth speech evaluation and defer the mental status examination to another time.
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d. Proceed with the examination and assess the patient for suicidal thoughts because
dysarthria is often accompanied by severe depression. ANS: A
In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions. Dysarthric speech and lethargy are signs of altered consciousness and answers to questions on the mental status examination may be invalid. The nurse should not proceed with any further part of the mental status examination at this time. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 9. A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black
combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. Which is an appropriate conclusion for the nurse draw? a. She probably does not have any problems. b. She is only trying to shock people and that her dress should be ignored. c. She has a manic syndrome because of her abnormal dress and grooming. d. More information should be gathered to decide whether her dress is appropriate. ANS: D
Grooming and hygiene should be noted—the person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person’s economic status or a deliberate fashion trend. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 10. A patient has been in the intensive care unit for 10 days. He has just been moved to the
medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient’s tests of cognitive function? a. May display some disruption in thought content. b. Will state, “I am so relieved to be out of intensive care.” c. Will be oriented to place and person, but the patient may not be certain of the date. d. May show evidence of some clouding of his level of consciousness. ANS: C
The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, “Some people have trouble keeping up with the dates while in the hospital. Do you know today’s date?” Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.
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DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 11. During a mental status examination, the nurse wants to assess a patient’s affect. Which
question the nurse should ask? a. “How do you feel today?” b. “Would you please repeat the following words?” c. “Have these medications had any effect on your pain?” d. “Has this pain affected your ability to get dressed by yourself?” ANS: A
Mood and affect should be judged by observing body language and facial expression and by directly asking, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and should appropriately change with the topics. Options B, C, and D do not assess affect. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 12. The nurse is planning to assess new memory with a patient. Which is the best way for the
nurse to do this? a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic. ANS: C
To assess new memory, the nurse should ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person’s ability to lay down new memories and is a highly sensitive and valid memory test. The FACT test, describing his first job, or describing the television show he was watching before coming to the clinic, does not test new memory. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 13. A 45-year-old woman is at the clinic for a mental status assessment. Which describes the
expecting findings on the Four Unrelated Words Test? a. Invents four unrelated words within 5 minutes b. Invents four unrelated words within 30 seconds c. Recalls four unrelated words after a 30-minute delay d. Recalls four unrelated words after a 60-minute delay ANS: C
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The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, “I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them.” After 5 minutes, ask for the four words. The normal response for people under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 14. During a mental status assessment, which question by the nurse would best assess a person’s
judgment? a. “Do you feel that you are being watched, followed, or controlled?” b. “Tell me what you plan to do once you are discharged from the hospital.” c. “What does the statement, ‘People in glass houses shouldn’t throw stones,’ mean to you?” d. “What would you do if you found a stamped, addressed envelope lying on the sidewalk?” ANS: B
A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person’s response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person’s judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations, and the capacity for violent or suicidal behavior. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 15. Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to
kill herself d. Older adult man who tells the nurse that he is going to “join his wife in heaven”
tomorrow and plans to use a gun ANS: D
When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk for physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 16. The nurse is assessing orientation in a 79-year-old patient. Which of these responses would
lead the nurse to conclude that this patient is oriented? a. “I know my name is John. I couldn’t tell you where I am. I think it is 2010,
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though.” b. “I know my name is John, but to tell you the truth, I get kind of confused about the date.” c. “I know my name is John; I guess I’m at the hospital in Spokane. No, I don’t know the date.” d. “I know my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010.” ANS: D
Many aging people experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging people oriented if they generally know where they are and the present period. They should be considered oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., hospital) and the name of the town. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 17. The nurse is performing the Denver II screening test on a 12-month-old infant during a routine
well-child visit. What should the nurse tell the infant’s parents about the Denver II screening test? a. Tests three areas of development: cognitive, physical, and psychological b. Will indicate whether the child has a speech disorder so that treatment can begin c. Is a screening instrument designed to detect children who are slow in development d. Is a test to determine intellectual ability and may indicate whether problems will develop later in school ANS: C
The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens. The Denver II does not asses cognitive, physical, and psychological domains; is not an intelligence test and it does not predict current or future intellectual ability; and does not diagnose speech disorders or suggest treatment regimens. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 18. A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her
by calling her name, but the patient remains drowsy during the conversation. What is the best description of this patient’s level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Semi-coma ANS: A
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The term lethargic best describes a patient who drifts off to sleep when not being stimulated, can easily be aroused by calling his or her name, but remains drowsy during conversation. Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased. Obtunded is a transitional state between lethargy and stupor. Stuporous and semi-coma have the same meaning which is unconscious and responding only to persistent or vigorous shaking or pain. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate.
He seems driven to speak and says, “I buy obie get spirding and take my train.” What is the best description of this patient’s problem? a. Echolalia b. Global aphasia c. Broca’s aphasia d. Wernicke’s aphasia ANS: D
This type of communication illustrates Wernicke’s or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well-articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another person’s words or phrases. With global aphasia, spontaneous speech is absent or reduced to a few stereotyped words or sounds and comprehension is absent or reduced to only a person’s own name and a few select words. With Broca’s aphasia the person can understand language but cannot express himself using words or language. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 20. A patient repeatedly seems to have difficulty coming up with a word. He says, “I was on my
way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.” How should the nurse record this on his chart? a. Blocking b. Neologism c. Circumlocution d. Circumstantiality ANS: C
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Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object. The statement in the question is not an example of blocking, neologism, or circumstantiality. Blocking is when a person experiences sudden interruption in train of thought and unable to complete sentences which seems r/t strong emotion. Neologism involves coining a new word which is inventing or making up words that have no real meaning except for the person. Circumstantiality is when a person talks excessively with unnecessary detail and delays reaching the point. Their sentences have a meaningful connection but are irrelevant. The statement in the question is an example of circumlocution which is a roundabout expression, substituting a phrase when one cannot think of the name of the object. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which
statement by the patient is an example of flight of ideas? a. “My stomach hurts. Hurts, spurts, burts.” b. “Kiss, wood, reading, ducks, onto, maybe.” c. “I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.” d. “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.” ANS: D
Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words. Options A, B, and C are not examples of a flight of ideas that have an association. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 22. A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent
that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. What is the best description of this patient’s condition? a. A snake phobia b. A hypochondriac c. An obsession with snakes d. A delusion that snakes are harmful stemming from an early traumatic incident involving snakes ANS: A
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This is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. The situation in the question is not an example of hypochondria, an obsession, or a delusion. A hypochondriac is a person who is morbidly worried about his/her own health and/or feels sick with no actual basis for that assumption. An obsession is an unwanted, persistent thought or impulse in which logic will not purge him/her from his/her consciousness and is intrusive and senseless. A delusion is a firm, fixed, false belief that is irrational and that a person clings to despite objective evidence to the contrary. Instead, the situation in the question is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 23. During a recent interview, a patient diagnosed with schizophrenia shows the nurse a picture of
a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. What is the best description of this behavior? a. Confusion b. Ambivalence c. Depersonalization d. Inappropriate affect ANS: D
This is an example of inappropriate affect. An inappropriate affect is an affect clearly discordant with the content of the person’s speech. The patient’s behavior is not an example of confusion, ambivalence, or depersonalization. Confusion is a disturbance of consciousness characterized by inability to engage in orderly thought or by lack of power to distinguish, choose, or act decisively. Ambivalence is the existence of opposing emotions toward an idea, object, or person. Depersonalization is a loss of identity, feeling of being estranged, or perplexed about one’s own identity and meaning of existence. The example in the question demonstrates inappropriate affect. An inappropriate affect is an affect clearly discordant with the content of the person’s speech. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 24. During change of shift report, the nurse hears that a patient is experiencing hallucinations.
Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. b. Woman hears the doorbell ring and goes to answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket. ANS: A
Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
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