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Health Assessment Finals Review

Terms in this set (213)

1. After completing an initial ANS: A

assessment of a patient, the
nurse has charted that his
respirations are eupneic and his
pulse is 58 beats per minute.
These types of data would be:

a. Objective.

b. Reflective.

c. Subjective.

d. Introspective.

2. A patient tells the nurse that ANS: C

he is very nervous, is
nauseated, and "feels hot."
These types of data would be:

a. Objective.

b. Reflective.

c. Subjective.

d. Introspective.

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3. The patient's record, ANS: A

laboratory studies, objective
data, and subjective data
combine to form the:

a. Data base.

b. Admitting data.

c. Financial statement.

d. Discharge summary.

4. When listening to a patient's ANS: C

breath sounds, the nurse is
unsure of a sound that is heard.
The nurse's next action should
be to:

a. Immediately notify the

patient's physician.

b. Document the sound exactly

as it was heard.

c. Validate the data by asking a

coworker to listen to the breath
sounds.

d. Assess again in 20 minutes to

note whether the sound is still
present.

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5. The nurse is conducting a ANS: B

class for new graduate nurses.
During the teaching session,
the nurse should keep in mind
that novice nurses, without a
background of skills and
experience from which to draw,
are more likely to make their
decisions using:

a. Intuition.

b. A set of rules.

c. Articles in journals.

d. Advice from supervisors.

6. Expert nurses learn to attend ANS: A

to a pattern of assessment data
and act without consciously
labeling it. These responses are
referred to as:

a. Intuition.

b. The nursing process.

c. Clinical knowledge.
d. Diagnostic reasoning.

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7. The nurse is reviewing ANS: C

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. The patient's own

preferences are not important
with EBP.

8. The nurse is conducting a ANS: D

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

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9. When considering priority ANS: C

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

10. Which critical thinking skill ANS: B

helps the nurse see
relationships among the data?

a. Validation

b. Clustering related cues

c. Identifying gaps in data

d. Distinguishing relevant from

irrelevant

11. The nurse knows that A

developing appropriate
nursing interventions for a
patient relies on the
appropriateness of the __________
diagnosis.

a. Nursing

b. Medical

c. Admission

d. Collaborative

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12. The nursing process is a D

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

13. A newly admitted patient is A

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

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14. Which of these would be A

formulated by a nurse using
diagnostic reasoning?

a. Nursing diagnosis

b. Medical diagnosis

c. Diagnostic hypothesis

d. Diagnostic assessment

15. Barriers to incorporating A

EBP include:

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.

16. What step of the nursing D

process includes data
collection by health history,
physical examination, and
interview?

a. Planning

b. Diagnosis

c. Evaluation

d. Assessment

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17. During a staff meeting, D

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.

18. When reviewing the D

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.

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19. The nurse recognizes that C

the concept of prevention in
describing health is essential
because:

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.

20. The nurse is performing a d

physical assessment on a newly
admitted patient. An example
of objective information
obtained during the physical
assessment includes the:

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.

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21. A visiting nurse is making an c

initial home visit for a patient
who has many chronic medical
problems. Which type of data
base is most appropriate to
collect in this setting?

a. A follow-up data base to

evaluate changes at
appropriate intervals

b. An episodic data base

because of the continuing,
complex medical problems of
this patient

c. A complete health data base

because of the nurse's primary
responsibility for monitoring
the patient's health

d. An emergency data base

because of the need to collect
information and make accurate
diagnoses rapidly

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22. Which situation is most d

appropriate during which the
nurse performs 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 surgery the
following day.

d. Patient in an outpatient clinic

has cold and influenza-like
symptoms.

23. A patient is at the clinic to A

have her blood pressure
checked. She has been coming
to the clinic weekly since she
changed medications 2 months
ago. The nurse should:

a. Collect a follow-up data

base and then check her blood
pressure.

b. Ask her to read her health

record and indicate any
changes since her last visit.

c. Check only her blood

pressure because her
complete health history was
documented 2 months ago.
d. Obtain a complete health
history before checking her
blood pressure because much
of her history information may
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24. A patient is brought by B

ambulance to the emergency
department with multiple
traumas 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 life-
saving measures.

b. Simultaneously ask history

questions while performing the
examination and initiating life-
saving measures.

c. Collect all information on the

history form, including social
support patterns, strengths,
and coping patterns.

d. Perform life-saving measures

and delay asking any history
questions until the patient is
transferred to the intensive
care unit.

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25. A 42-year-old patient of D

Asian descent is being seen at
the clinic for an initial
examination. The nurse knows
that including cultural
information in his health
assessment is important to:

a. Identify the cause of his

illness.

b. Make accurate disease

diagnoses.

c. Provide cultural health rights

for the individual.

d. Provide culturally sensitive

and appropriate care.

26. In the health promotion D

model, the focus of the health
professional includes:

a. Changing the patient's

perceptions of disease.

b. Identifying biomedical
model interventions.

c. Identifying negative health

acts of the consumer.

d. Helping the consumer

choose a healthier lifestyle.

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27. The nurse has implemented C

several planned interventions
to address the nursing
diagnosis of acute pain. Which
would be the next appropriate
action?

a. Establish priorities.

b. Identify expected outcomes.

c. Evaluate the individual's

condition, and compare actual
outcomes with expected
outcomes.

d. Interpret data, and then

identify clusters of cues and
make inferences.

28. Which statement best D

describes a proficient nurse? A
proficient nurse is one who:

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.

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1. The nurse is reviewing data ANS: A, C, E, F

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

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Put the following patient 1. ANS: B

situations in order according to

the level of priority.
2. ANS: C

a. A patient newly diagnosed

with type 2 diabetes mellitus 3. ANS: A
does not know how to check
his own blood glucose levels
with a glucometer.

b. A teenager who was stung

by a bee during a soccer match
is having trouble breathing.

c. An older adult with a urinary

tract infection is also showing
signs of confusion and
agitation.

1. a = First-level priority
problem

2. b = Second-level priority
problem

3. c = Third-level priority
problem

CHAPTER 2 ...

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1. The nurse is reviewing the ANS: B

development of culture. Which
statement is correct regarding
the development of one's
culture? Culture is:

a. Genetically determined on
the basis of racial background.

b. Learned through language

acquisition and socialization.

c. A nonspecific phenomenon
and is adaptive but
unnecessary.

d. Biologically determined on
the basis of physical
characteristics.

2. During a class on the aspects ANS: D

of culture, the nurse shares that
culture has four basic
characteristics. Which
statement correctly reflects
one of these characteristics?

a. Cultures are static and

unchanging, despite changes
around them.

b. Cultures are never specific,

which makes them hard to
identify.

c. Culture is most clearly

reflected in a person's
language and behavior.

d. Culture adapts to specific

environmental factors and
available natural resources.

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3. During a seminar on cultural ANS: C

aspects of nursing, the nurse The culture that develops in any given society is
recognizes that the definition always specific and distinctive, encompassing all of
stating "the specific and distinct the knowledge, beliefs, customs, and skills acquired
knowledge, beliefs, skills, and by members of the society. The other terms do not
customs acquired by members fit the given definition.

of a society" reflects which

term?
DIF: Cognitive Level: Remembering (Knowledge)
a. Mores
REF: p. 14

b. Norms
MSC: Client Needs: Psychosocial Integrity
c. Culture

d. Social learning

4. When discussing the use of ANS: D

the term subculture, the nurse Within cultures, groups of people share different
recognizes that it is best beliefs, values, and attitudes. Differences occur
described as:
because of ethnicity, religion, education,
a. Fitting as many people into occupation, age, and gender. When such groups
the majority culture as possible.
function within a large culture, they are referred to
b. Defining small groups of as subcultural groups.

people who do not want to be

identified with the larger DIF: Cognitive Level: Understanding
culture.
(Comprehension) REF: p. 14

c. Singling out groups of MSC: Client Needs: Psychosocial Integrity

people who suffer differential
and unequal treatment as a
result of cultural variations.

d. Identifying fairly large

groups of people with shared
characteristics that are not
common to all members of a
culture.

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5. When reviewing the ANS: A

demographics of ethnic groups Hispanics are the largest and fastest growing
in the United States, the nurse population in the United States, followed by Asians,
recalls that the largest and Blacks, American Indians and Alaska natives, and
fastest growing population is:
other groups.

a. Hispanic.

b. Black.
DIF: Cognitive Level: Remembering (Knowledge)
c. Asian.
REF: p. 11

d. American Indian. MSC: Client Needs: General

6. During an assessment, the ANS: A

nurse notices that a patient is The nurse should inquire about the amulet's
handling a small charm that is meaning. Amulets, such as charms, are often
tied to a leather strip around considered an important means of protection from
his neck. Which action by the "evil spirits" by some cultures.

nurse is appropriate?

a. Ask the patient about the DIF: Cognitive Level: Applying (Application) REF: p.
item and its significance.
19

b. Ask the patient to lock the MSC: Client Needs: Psychosocial Integrity
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.

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7. The nurse manager is ANS: D

explaining culturally competent Culturally competent implies that the caregiver

care during a staff meeting. understands and attends to the total context of the
Which statement accurately individual's situation. This competency includes
describes the concept of awareness of immigration status, stress factors,
culturally competent care? other social factors, and cultural similarities and
"The caregiver:
differences. It does not require the caregiver to
a. Is able to speak the patient's speak the patient's native language.

native language."

b. Possesses some basic DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24

knowledge of the patient's MSC: Client Needs: Psychosocial Integrity

cultural background."

c. Applies the proper

background knowledge of a
patient's cultural background to
provide the best possible
health care."
d. Understands and attends to
the total context of the
patient's situation."

8. The nurse recognizes that an ANS: B

example of a person who is Someone who is heritage consistent lives a lifestyle

heritage consistent would be a:
that reflects his or her traditional heritage, not the
a. Woman who has adapted her norms and customs of the new country.

clothing to the clothing style of

her new country.
DIF: Cognitive Level: Understanding
b. Woman who follows the (Comprehension) REF: p. 24

traditions that her mother MSC: Client Needs: Psychosocial Integrity

followed regarding meals.

c. Man who is not sure of his

ancestor's country of origin.

d. Child who is not able to

speak his parents' native
language.
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9. After a class on culture and ANS: C

ethnicity, the new graduate Ethnicity pertains to a social group within the social
nurse reflects a correct system that claims to have variable traits, such as a
understanding of the concept common geographic origin, migratory status,
of ethnicity with which religion, race, language, values, traditions, symbols,
statement?
or food preferences. Culture is dynamic, ever
a. "Ethnicity is dynamic and changing, and learned from birth through the
ever changing."
processes of language acquisition and socialization.
b. "Ethnicity is the belief in a Religion is the belief in a higher power.

higher power."

c. "Ethnicity pertains to a social DIF: Cognitive Level: Applying (Application) REF: p.

group within the social system 14

that claims shared values and MSC: Client Needs: Psychosocial Integrity
traditions."

d. "Ethnicity is learned from

birth through the processes of
language acquisition and
socialization."

10. The nurse is comparing the ANS: C

concepts of religion and Spirituality refers to each person's unique life

spirituality. Which of the experiences and his or her personal effort to find
following is an appropriate purpose and meaning in life. The other responses
component of one's apply to religion.

spirituality?

a. Belief in and the worship of DIF: Cognitive Level: Applying (Application) REF: p.
God or gods
15

b. Attendance at a specific MSC: Client Needs: Psychosocial Integrity

church or place of worship

c. Personal effort made to find

purpose and meaning in life

d. Being closely tied to one's

ethnic background

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11. A woman who has lived in ANS: A

the United States for a year Assimilation is the process by which a person
after moving from Europe has develops a new cultural identity and becomes like
learned to speak English and is members of the dominant culture. This concept does
almost finished with her not reflect heritage consistency. Biculturalism is a
college studies. She now dual pattern of identification; acculturation is the
dresses like her peers and says process of adapting to and acquiring another
that her family in Europe would culture.

hardly recognize her. This nurse

recognizes that this situation DIF: Cognitive Level: Understanding
illustrates which concept?
(Comprehension) REF: p. 15

a. Assimilation
MSC: Client Needs: Psychosocial Integrity
b. Heritage consistency

c. Biculturalism

d. Acculturation

12. The nurse is conducting a ANS: B

heritage assessment. Which Asking questions about participation in the religious

question is most appropriate traditions of family enables the nurse to assess a
for this assessment?
person's heritage. Simply asking about one's religion,
a. "What is your religion?"
smoking history, or health history does not reflect
b. "Do you mostly participate in heritage.

the religious traditions of your

family?"
DIF: Cognitive Level: Applying (Application) REF: p.
c. "Do you smoke?"
24

d. "Do you have a history of MSC: Client Needs: Psychosocial Integrity

heart disease?"

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13. In the majority culture of ANS: B

America, coughing, sweating, The nurse needs to identify the meaning of health to
and diarrhea are symptoms of the patient, remembering that concepts are derived,
an illness. For some individuals in part, from the way in which members of the
of Mexican-American origin, cultural group define health.

however, these symptoms are a

normal part of living. The nurse DIF: Cognitive Level: Understanding
recognizes that this difference (Comprehension) REF: p. 17

is true, probably because MSC: Client Needs: Psychosocial Integrity

Mexican-Americans:

a. Have less efficient immune

systems and are often ill.

b. Consider these symptoms

part of normal living, not
symptoms of ill health.

c. Come from Mexico, and

coughing is normal and healthy
there.

d. Are usually in a lower

socioeconomic group and are
more likely to be sick.

ANS: B

14. The nurse is reviewing

Among the biomedical explanations for disease is
theories of illness. The germ
the germ theory, which states that microscopic
theory, which states that
organisms such as bacteria and viruses are
microscopic organisms such as
responsible for specific disease conditions. The
bacteria and viruses are
naturalistic, or holistic, perspective holds that the
responsible for specific disease
forces of nature must be kept in natural balance. The
conditions, is a basic belief of
magicoreligious perspective holds that supernatural
which theory of illness?

forces dominate and cause illness or health.

a. Holistic

b. Biomedical

DIF: Cognitive Level: Understanding

c. Naturalistic

(Comprehension) REF: p. 18

d. Magicoreligious
MSC: Client Needs: Psychosocial Integrity
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15. An Asian-American woman ANS: A

is experiencing diarrhea, which Yin foods are cold and yang foods are hot. Cold
is believed to be "cold" or "yin." foods are eaten with a hot illness, and hot foods are
The nurse expects that the eaten with a cold illness. The other explanations do
woman is likely to try to treat it not reflect the yin/yang theory.

with:

a. Foods that are "hot" or DIF: Cognitive Level: Applying (Application) REF: p.
"yang."
18

b. Readings and Eastern MSC: Client Needs: Psychosocial Integrity

medicine meditations.

c. High doses of medicines

believed to be "cold."

d. No treatment is tried
because diarrhea is an
expected part of life.

16. Many Asians believe in the ANS: C

yin/yang theory, which is Many Asians believe in the yin/yang theory, in which
rooted in the ancient Chinese health is believed to exist when all aspects of the
philosophy of Tao. Which person are in perfect balance. The other statements
statement most accurately do not describe this theory.

reflects "health" in an Asian with

this belief?
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 18

a. A person is able to work and MSC: Client Needs: Psychosocial Integrity

produce.

b. A person is happy, stable,

and feels good.
c. All aspects of the person are
in perfect balance.

d. A person is able to care for

others and function socially.

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ANS: A

17. Illness is considered part of

The naturalistic perspective states that the laws of
life's rhythmic course and is an
nature create imbalances, chaos, and disease. From
outward sign of disharmony
the perspective of the Chinese, for example, illness
within. This statement most
is not considered an introducing agent; rather,
accurately reflects the views
illness is considered a part of life's rhythmic course
about illness from which
and an outward sign of disharmony within. The other
theory?

options are not correct.

a. Naturalistic

b. Biomedical

DIF: Cognitive Level: Understanding

c. Reductionist

(Comprehension) REF: p. 18

d. Magicoreligious
MSC: Client Needs: Psychosocial Integrity

ANS: B

18. An individual who takes the The basic premise of the magicoreligious
magicoreligious perspective of perspective is that the world is seen as an arena in
illness and disease is likely to which supernatural forces dominate. The fate of the
believe that his or her illness world and those in it depends on the actions of
was caused by:
supernatural forces for good or evil. The other
a. Germs and viruses.
answers do not reflect the magicoreligious
b. Supernatural forces.
perspective.

c. Eating imbalanced foods.

d. An imbalance within his or DIF: Cognitive Level: Understanding

her spiritual nature. (Comprehension) REF: p. 18

MSC: Client Needs: Psychosocial Integrity

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19. If an American Indian ANS: C

woman has come to the clinic When self-treatment is unsuccessful, the individual
to seek help with regulating her may turn to the lay or folk healing systems, to
diabetes, then the nurse can spiritual or religious healing, or to scientific
expect that she:
biomedicine. In addition to seeking help from a
a. Will comply with the biomedical or scientific health care provider,
treatment prescribed.
patients may also seek help from folk or religious
b. Has obviously given up her healers.

belief in naturalistic causes of

disease.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 19

c. May also be seeking the MSC: Client Needs: Psychosocial Integrity

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.

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20. An older Mexican- ANS: C

American woman with In addition to seeking help from the biomedical or

traditional beliefs has been scientific health care provider, patients may also
admitted to an inpatient care seek help from folk or religious healers. Some
unit. A culturally sensitive nurse people, such as those of Mexican-American or
would:
American-Indian origins, may believe that the cure is
a. Contact the hospital incomplete unless the body, mind, and spirit are also
administrator about the best healed (although the division of the person into
course of action.
parts is a Western concept).

b. Automatically get a
curandero for her, because DIF: Cognitive Level: Analyzing (Analysis) REF: p. 19

requesting one herself is not MSC: Client Needs: Psychosocial Integrity

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.

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21. A 63-year-old Chinese- ANS: D

American man enters the Wide cultural variations exist in the manner in which
hospital with complaints of certain symptoms and disease conditions are
chest pain, shortness of breath, perceived, diagnosed, labeled, and treated.
and palpitations. Which Chinese-Americans sometimes convert mental
statement most accurately experiences or states into bodily symptoms (e.g.,
reflects the nurse's best course complaining of cardiac symptoms because the
of action?
center of emotion in the Chinese culture is the
a. The nurse should focus on heart).

performing a full cardiac

assessment.
DIF: Cognitive Level: Analyzing (Analysis) REF: pp.
b. The nurse should focus on 17-18

psychosomatic complaints MSC: Client Needs: Psychosocial Integrity

because the patient has just
learned that his wife has
cancer.

c. This patient is not in any

danger at present; therefore,
the nurse should send him
home with instructions to
contact his physician.

d. It is unclear what is
happening with this patient;
consequently, the nurse should
perform an assessment in both
the physical and the
psychosocial realms.

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22. Symptoms, such as pain, are ANS: B

often influenced by a person's Silent suffering is a potential response to pain in

cultural heritage. Which of the many cultures. The nurse's assessment of pain needs
following is a true statement to be embedded in a cultural context. The other
regarding pain?
responses are not correct.

a. Nurses' attitudes toward their

patients' pain are unrelated to DIF: Cognitive Level: Understanding
their own experiences with (Comprehension) REF: p. 22

pain.
MSC: Client Needs: Psychosocial Integrity
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.

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23. The nurse is reviewing ANS: B

concepts of cultural aspects of In addition to expecting variations in pain

pain. Which statement is true perception and tolerance, the nurse should expect
regarding pain?
variations in the expression of pain. It is well known
a. All patients will behave the that individuals turn to their social environment for
same way when in pain.
validation and comparison. The other statements are
b. Just as patients vary in their incorrect.

perceptions of pain, so will

they vary in their expressions of DIF: Cognitive Level: Understanding
pain.
(Comprehension) REF: p. 22

c. Cultural norms have very MSC: Client Needs: Psychosocial Integrity

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.

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24. During a class on religion ANS: D

and spirituality, the nurse is Spirituality arises out of each person's unique life
asked to define spirituality. experience and his or her personal effort to find
Which answer is correct? purpose and meaning in life. The other definitions
"Spirituality:
reflect the concept of religion.

a. Is a personal search to
discover a supreme being."
DIF: Cognitive Level: Understanding
b. Is an organized system of (Comprehension) REF: p. 15

beliefs concerning the cause, MSC: Client Needs: Psychosocial Integrity

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. Arises out of each person's

unique life experience and his
or her personal effort to find
purpose in life."

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25. The nurse recognizes that ANS: A

working with children with a Illness during childhood may be an especially

different cultural perspective difficult clinical situation. Children, as well as adults,
may be especially difficult have spiritual needs that vary according to the
because:
child's developmental level and the religious climate
a. Children have spiritual needs that exists in the family. The other statements are not
that are influenced by their correct.

stages of development.

b. Children have spiritual needs DIF: Cognitive Level: Applying (Application) REF: p.
that are direct reflections of 21

what is occurring in their MSC: Client Needs: Psychosocial Integrity

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.

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26. A 30-year-old woman has ANS: A

recently moved to the United Culture shock is a term used to describe the state of
States with her husband. They disorientation or inability to respond to the behavior
are living with the woman's of a different cultural group because of its sudden
sister until they can get a home strangeness, unfamiliarity, and incompatibility with
of their own. When company the individual's perceptions and expectations. The
arrives to visit with the woman's other terms are not correct.

sister, the woman feels

suddenly shy and retreats to DIF: Cognitive Level: Analyzing (Analysis) REF: pp.
the back bedroom to hide until 21-22

the company leaves. She MSC: Client Needs: Psychosocial Integrity

explains that her reaction to
guests is simply because she
does not know how to speak
"perfect English." This woman
could be experiencing:

a. Culture shock.
b. Cultural taboos.

c. Cultural unfamiliarity.

d. Culture disorientation.

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27. After a symptom is ANS: D

recognized, the first effort at After a symptom is identified, the first effort at
treatment is often self-care. treatment is often self-care. The availability of over-
Which of the following the-counter medications, the relatively high literacy
statements about self-care is level of Americans, and the influence of the mass
true? "Self-care is:
media in communicating health-related information
a. Not recognized as valuable to the general population have contributed to the
by most health care providers."
high percentage of cases of self-treatment.

b. Usually ineffective and may

delay more effective DIF: Cognitive Level: Understanding
treatment."
(Comprehension) REF: p. 19

c. Always less expensive than MSC: Client Needs: Psychosocial Integrity

biomedical alternatives."

d. Influenced by the
accessibility of over-the-
counter medicines."

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28. The nurse is reviewing the ANS: D

hot/cold theory of health and The hot/cold theory of health and illness is based
illness. Which statement best on the four humors of the body: blood, phlegm,
describes the basic tenets of black bile, and yellow bile. These humors regulate
this theory?
the basic bodily functions, described in terms of
a. The causation of illness is temperature, dryness, and moisture. The treatment
based on supernatural forces of disease consists of adding or subtracting cold,
that influence the humors of heat, dryness, or wetness to restore the balance of
the body.
the humors. The other statements are not correct.

b. Herbs and medicines are

classified on their physical DIF: Cognitive Level: Understanding
characteristics of hot and cold (Comprehension) REF: p. 18

and the humors of the body.

MSC: Client Needs: Psychosocial Integrity
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.

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29. In the hot/cold theory, ANS: D

illnesses are believed to be Illnesses believed to be caused by cold entering

caused by hot or cold entering the body include earache, chest cramps,
the body. Which of these gastrointestinal discomfort, rheumatism, and
patient conditions is most tuberculosis. Those illnesses believed to be caused
consistent with a cold by heat, or overheating, include sore throats,
condition?
abscessed teeth, rashes, and kidney disorders.

a. Patient with diabetes and

renal failure
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 18

b. Teenager with an abscessed MSC: Client Needs: Psychosocial Integrity

tooth

c. Child with symptoms of

itching and a rash

d. Older man with

gastrointestinal discomfort

30. When providing culturally ANS: D

competent care, nurses must The nurse needs to assess the cultural beliefs and
incorporate cultural practices of the patient. American Indians may seek
assessments into their health assistance from a medicine man or shaman, but the
assessments. Which statement nurse should not assume this. An open-ended
is most appropriate to use question regarding cultural and spiritual beliefs is
when initiating an assessment best used initially when performing a cultural
of cultural beliefs with an older assessment.

American-Indian patient?

a. "Are you of the Christian DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24

faith?"
MSC: Client Needs: Psychosocial Integrity
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?"

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31. During a class on cultural ANS: C

practices, the nurse hears the Cultural taboos are practices that are to be avoided,
term cultural taboo. Which such as receiving blood products, eating pork, and
statement illustrates the consuming caffeine. The other answers do not
concept of a cultural taboo?
reflect cultural taboos.

a. Believing that illness is a

punishment of sin
DIF: Cognitive Level: Applying (Application) REF: p.
b. Trying prayer before seeking 21

medical help
MSC: Client Needs: Psychosocial Integrity
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: D

Within cultures, groups of people share different

32. The nurse recognizes that
beliefs, values, and attitudes. Differences occur
categories such as ethnicity,
because of ethnicity, religion, education,
gender, and religion illustrate
occupation, age, and gender. When such groups
the concept of:

function within a large culture, they are referred to

a. Family.

as subcultural groups.

b. Cultures.

c. Spirituality.

DIF: Cognitive Level: Understanding

d. Subcultures.
(Comprehension) REF: p. 14

MSC: Client Needs: Psychosocial Integrity

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ANS: B

Religion is defined as an organized system of beliefs

33. The nurse is reviewing
concerning the cause, nature, and purpose of the
concepts related to one's
universe, especially belief in or the worship of God
heritage and beliefs. The belief
or gods. Spirituality is born out of each person's
in divine or superhuman
unique life experiences and his or her personal
power(s) to be obeyed and
efforts to find purpose and meaning in life. Ethnicity
worshipped as the creator(s)
pertains to a social group within the social system
and ruler(s) of the universe is
that claims to possess variable traits, such as a
known as:

common geographic origin, religion, race, and

a. Culture.

others.

b. Religion.

c. Ethnicity.

DIF: Cognitive Level: Remembering (Knowledge)

d. Spirituality.
REF: p. 15

MSC: Client Needs: Psychosocial Integrity

ANS: D

34. When planning a cultural

Health-related beliefs and practices are one
assessment, the nurse should
component of a cultural assessment. The other items
include which component?

reflect other aspects of the patient's history.

a. Family history

b. Chief complaint

DIF: Cognitive Level: Understanding

c. Medical history

(Comprehension) REF: p. 24

d. Health-related beliefs
MSC: Client Needs: Psychosocial Integrity

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35. Which of the following ANS: D

reflects the traditional health The belief that health is being in harmony with
and illness beliefs and nature reflects the health beliefs of those of African
practices of those of African heritages. The other examples represent Iberian and
heritage? Health is:
Central and South American heritages, American-
a. Being rewarded for good Indian heritages, and Asian heritages (See Table 2-
behavior.
3).

b. The balance of the body and

spirit.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 20

c. Maintained by wearing jade MSC: Client Needs: Psychosocial Integrity

amulets.

d. Being in harmony with

nature.

1. The nurse is reviewing ANS: B, D, E

aspects of cultural care. Which Patients should be examined within the context of
statements illustrate proper their own cultural health and illness practices.
cultural care? Select all that Questions should be simply stated and not rapidly
apply.
asked.

a. Examine the patient within

the context of one's own DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24

cultural health and illness MSC: Client Needs: Psychosocial Integrity

practices.

b. Select questions that are not

complex.

c. Ask questions rapidly.

d. Touch patients within the

cultural boundaries of their
heritage.

e. Pace questions throughout

the physical examination.

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2. The nurse is asking questions ANS: A, C, D, F

about a patient's health beliefs. The questions listed are appropriate questions for
Which questions are an assessment of a patient's health beliefs and
appropriate? Select all that practices. The questions regarding family history and
apply.
surgeries are part of the patient's physical history,
a. "What is your definition of not the patient's health beliefs.

health?"

b. "Does your family have a DIF: Cognitive Level: Applying (Application) REF: p.
history of cancer?"
17

c. "How do you describe MSC: Client Needs: Psychosocial Integrity

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?"

CHAPTER 3 ...

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1. The nurse is conducting an ANS: B

interview with a woman who Communication is all behaviors, conscious and

has recently learned that she is unconscious, verbal and nonverbal. All behaviors
pregnant and who has come to have meaning. Her behavior does not imply that she
the clinic today to begin is nervous about labor, upset by her husband, or
prenatal care. The woman worried about the nurse's response.

states that she and her husband

are excited about the DIF: Cognitive Level: Analyzing (Analysis) REF: p. 28

pregnancy but have a few MSC: Client Needs: Psychosocial Integrity

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? The
woman is:

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.

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2. Receiving is a part of the ANS: C

communication process. Which The receiver attaches meaning determined by his or

receiver is most likely to her experiences, culture, self-concept, and current
misinterpret a message sent by physical and emotional states. The man whose wife
a health care professional?
has just been diagnosed with lung cancer may be
a. Well-adjusted adolescent experiencing emotions that affect his receiving.

who came in for a sports

physical
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 28

b. Recovering alcoholic who MSC: Client Needs: Psychosocial Integrity

came in for a basic physical
examination

c. Man whose wife has just

been diagnosed with lung
cancer

d. Man with a hearing

impairment who uses sign
language to communicate and
who has an interpreter with him

3. The nurse makes which ANS: A

adjustment in the physical The nurse should reduce noise by turning off the
environment to promote the television, radio, and other unnecessary equipment,
success of an interview?
because multiple stimuli are confusing. The
a. Reduces noise by turning off interviewer and patient should be approximately 4
televisions and radios
to 5 feet apart; the room should be well-lit,
b. Reduces the distance enabling the interviewer and patient to see each
between the interviewer and other clearly. Having a table or desk in between the
the patient to 2 feet or less
two people creates the idea of a barrier; equal-
c. Provides a dim light that status seating, at eye level, is better.

makes the room cozy and

helps the patient relax
DIF: Cognitive Level: Applying (Application) REF: p.
d. Arranges seating across a 29

desk or table to allow the MSC: Client Needs: Psychosocial Integrity

patient some personal space

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4. In an interview, the nurse ANS: A

may find it necessary to take The use of history forms and note-taking may be
notes to aid his or her memory unavoidable. However, the nurse must be aware that
later. Which statement is true note-taking during the interview has disadvantages.
regarding note-taking?
It breaks eye contact too often and shifts the
a. Note-taking may impede the attention away from the patient, which diminishes his
nurse's observation of the or her sense of importance. Note-taking may also
patient's nonverbal behaviors.
interrupt the patient's narrative flow, and it impedes
b. Note-taking allows the the observation of the patient's nonverbal behavior.

patient to continue at his or her

own pace as the nurse records DIF: Cognitive Level: Understanding
what is said.
(Comprehension) REF: p. 30

c. Note-taking allows the nurse MSC: Client Needs: Psychosocial Integrity

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.

5. The nurse asks, "I would like ANS: D

to ask you some questions When gathering a complete history, the nurse
about your health and your should give the reason for the interview during the
usual daily activities so that we opening or introduction phase of the interview, not
can better plan your stay here." during or at the end of the interview.

This question is found at the

__________ phase of the interview DIF: Cognitive Level: Understanding
process.
(Comprehension) REF: p. 31

a. Summary
MSC: Client Needs: Psychosocial Integrity
b. Closing

c. Body

d. Opening or introduction

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6. A woman has just entered ANS: D

the emergency department Address the person by using his or her surname. The
after being battered by her nurse should introduce him or herself and give the
husband. The nurse needs to reason for the interview. Friendly small talk is not
get some information from her needed to build rapport.

to begin treatment. What is the

best choice for an opening DIF: Cognitive Level: Applying (Application) REF: p.
phase of the interview with this 31

patient?
MSC: Client Needs: Psychosocial Integrity
a. "Hello, Nancy, my name is
Mrs. C."

b. "Hello, Mrs. H., my name is

Mrs. C. It sure is cold today!"

c. "Mrs. H., my name is Mrs. C.

How are you?"

d. "Mrs. H., my name is Mrs. C.

I'll need to ask you a few
questions about what
happened."

ANS: D

7. During an interview, the

The open-ended question asks for narrative
nurse states, "You mentioned
information. It states the topic to be discussed but
having shortness of breath. Tell
only in general terms. The nurse should use it to
me more about that." Which
begin the interview, to introduce a new section of
verbal skill is used with this
questions, and whenever the person introduces a
statement?

new topic.

a. Reflection

b. Facilitation

DIF: Cognitive Level: Understanding

c. Direct question

(Comprehension) REF: p. 31

d. Open-ended question
MSC: Client Needs: Psychosocial Integrity

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8. A patient has finished giving ANS: D

the nurse information about the The nurse should use direct questions after the
reason he is seeking care. person's opening narrative to fill in any details he or
When reviewing the data, the she left out. The nurse also should use direct
nurse finds that some questions when specific facts are needed, such as
information about past when asking about past health problems or during
hospitalizations is missing. At the review of systems.

this point, which statement by

the nurse would be most DIF: Cognitive Level: Applying (Application) REF: p.
appropriate to gather these 31

data?
MSC: Client Needs: Psychosocial Integrity
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
hospitalizations. When was the
last time you were admitted for
chest pain?"

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9. In using verbal responses to ANS: D

assist the patient's narrative, When the health care provider uses the response of
some responses focus on the confrontation, the frame of reference shifts from the
patient's frame of reference patient's perspective to the perspective of the
and some focus on the health health care provider, and the health care provider
care provider's perspective. An starts to express his or her own thoughts and
example of a verbal response feelings. Empathy, reflection, and facilitation
that focuses on the health care responses focus on the patient's frame of reference.

provider's perspective would

be:
DIF: Cognitive Level: Remembering (Knowledge)
a. Empathy.
REF: p. 32

b. Reflection.
MSC: Client Needs: Psychosocial Integrity
c. Facilitation.

d. Confrontation.

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10. When taking a history from a ANS: A

newly admitted patient, the Silent attentiveness communicates that the person
nurse notices that he often has time to think and to organize what he or she
pauses and expectantly looks wishes to say without an interruption from the nurse.
at the nurse. What would be Health professionals most often interrupt this
the nurse's best response to thinking silence. The other responses are not
this behavior?
conducive to ideal communication.

a. Be silent, and allow him to

continue when he is ready.
DIF: Cognitive Level: Applying (Application) REF: p.
b. Smile at him and say, "Don't 33

worry about all of this. I'm sure MSC: Client Needs: Psychosocial Integrity
we can find out why you're
having these pains."

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."

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11. A woman is discussing the ANS: B

problems she is having with her The nurse should use clarification when the person's
2-year-old son. She says, "He word choice is ambiguous or confusing (e.g., "Tell
won't go to sleep at night, and me what you mean by fits."). Clarification is also
during the day he has several used to summarize the person's words or to simplify
fits. I get so upset when that the words to make them clearer; the nurse should
happens." The nurse's best then ask if he or she is on the right track.

verbal response would be:

a. "Go on, I'm listening."

DIF: Cognitive Level: Applying (Application) REF: p.
b. "Fits? Tell me what you mean 33

by this." MSC: Client Needs: Psychosocial Integrity

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."

12. A 17-year-old single mother ANS: C

is describing how difficult it is An empathetic response recognizes the feeling and

to raise a 3-year-old child by puts it into words. It names the feeling, allows its
herself. During the course of expression, and strengthens rapport. Other
the interview she states, "I can't empathetic responses are, "This must be very hard
believe my boyfriend left me to for you," "I understand," or simply placing your hand
do this by myself! What a on the person's arm. Simply reflecting the person's
terrible thing to do to me!" words or agreeing with the person is not an
Which of these responses by empathetic response.

the nurse uses empathy?

a. "You feel alone."

DIF: Cognitive Level: Applying (Application) REF: p.
b. "You can't believe he left you 28

alone?"
MSC: Client Needs: Psychosocial Integrity
c. "It must be so hard to face
this all alone."

d. "I would be angry, too;

raising a child alone is no
picnic."

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13. A man has been admitted to ANS: D

the observation unit for In the case of confrontation, a certain action,

observation after being treated feeling, or statement has been observed, and the
for a large cut on his forehead. nurse now focuses the patient's attention on it. The
As the nurse works through the nurse should give honest feedback about what is
interview, one of the standard seen or felt. Confrontation may focus on a
questions has to do with discrepancy, or the nurse may confront the patient
alcohol, tobacco, and drug when parts of the story are inconsistent. The other
use. When the nurse asks him statements are not appropriate.

about tobacco use, he states, "I

quit smoking after my wife died DIF: Cognitive Level: Applying (Application) REF: p.
7 years ago." However, the 33

nurse notices an open pack of MSC: Client Needs: Psychosocial Integrity

cigarettes in his shirt pocket.
Using confrontation, the nurse
could say:
a. "Mr. K., I know that you are
lying."

b. "Mr. K., come on, tell me how

much you smoke."

c. "Mr. K., I didn't realize your

wife had died. It must be
difficult for you at this time.
Please tell me more about
that."

d. "Mr. K., you have said that

you don't smoke, but I see that
you have an open pack of
cigarettes in your pocket."

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14. The nurse has used ANS: B

interpretation regarding a Interpretation is not based on direct observation as

patient's statement or actions. is confrontation, but it is based on one's inference or
After using this technique, it conclusion. The nurse risks making the wrong
would be best for the nurse to:
inference. If this is the case, then the patient will
a. Apologize, because using correct it. However, even if the inference is correct,
interpretation can be interpretation helps prompt further discussion of the
demeaning for the patient.
topic.

b. Allow time for the patient to

confirm or correct the DIF: Cognitive Level: Analyzing (Analysis) REF: p. 33

inference.
MSC: Client Needs: Psychosocial Integrity
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.

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15. During an interview, a ANS: C

woman says, "I have decided This statement is not based on one's inference or
that I can no longer allow my conclusion. It links events, makes associations, or
children to live with their implies cause. Interpretation also ascribes feelings
father's violence, but I just can't and helps the person understand his or her own
seem to leave him." Using feelings in relation to the verbal message. The other
interpretation, the nurse's best statements do not reflect interpretation.

response would be:

a. "You are going to leave DIF: Cognitive Level: Applying (Application) REF: p.
him?"
33

b. "If you are afraid for your MSC: Client Needs: Psychosocial Integrity
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."

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16. A pregnant woman states, "I ANS: B

just know labor will be so By providing false assurance or reassurance, this

painful that I won't be able to courage builder relieves the woman's anxiety and
stand it. I know it sounds awful, gives the nurse the false sense of having provided
but I really dread going into comfort. However, for the woman, providing false
labor." The nurse responds by assurance or reassurance actually closes off
stating, "Oh, don't worry about communication, trivializes her anxiety, and
labor so much. I have been effectively denies any further talk of it.

through it, and although it is

painful, many good DIF: Cognitive Level: Analyzing (Analysis) REF: p. 32

medications are available to MSC: Client Needs: Psychosocial Integrity

decrease the pain." Which
statement is true regarding this
response? The nurse's reply
was a:

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.

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17. During a visit to the clinic, a ANS: B

patient states, "The doctor just Clarification should be used when the person's
told me he thought I ought to word choice is ambiguous or confusing. Clarification
stop smoking. He doesn't is also used to summarize the person's words or to
understand how hard I've tried. simplify the words to make them clearer; the nurse
I just don't know the best way should then ask if he or she is on the right track. The
to do it. What should I do?" The other responses give unwanted advice or do not
nurse's most appropriate offer a helpful response.

response in this case would be:

a. "I'd quit if I were you. The DIF: Cognitive Level: Applying (Application) REF: p.
doctor really knows what he is 33

talking about."
MSC: Client Needs: Psychosocial Integrity
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 smoking
cessation program we offer?"

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18. As the nurse enters a ANS: A

patient's room, the nurse finds Reflection echoes the patient's words, repeating
her crying. The patient states part of what the person has just said. Reflection can
that she has just found out that also help express the feelings behind a person's
the lump in her breast is cancer words.

and says, "I'm so afraid of, um,

you know." The nurse's most DIF: Cognitive Level: Applying (Application) REF: p.
therapeutic response would be 33

to say in a gentle manner:

MSC: Client Needs: Psychosocial Integrity
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."

19. A nurse is taking complete ANS: C

health histories on all of the This question is an example of using leading or

patients attending a wellness biased questions. Asking, "You don't smoke, do
workshop. On the history form, you?" implies that one answer is better than another.
one of the written questions If the person wants to please someone, then he or
asks, "You don't smoke, drink, she is either forced to answer in a way that
or take drugs, do you?" This corresponds to his or her implied values or is made
question is an example of:
to feel guilty when admitting the other answer.

a. Talking too much.

b. Using confrontation.
DIF: Cognitive Level: Understanding
c. Using biased or leading (Comprehension) REF: p. 34

questions.
MSC: Client Needs: Psychosocial Integrity
d. Using blunt language to deal
with distasteful topics.

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20. When observing a patient's ANS: D

verbal and nonverbal When nonverbal and verbal messages are

communication, the nurse congruent, the verbal message is reinforced. When
notices a discrepancy. Which they are incongruent, the nonverbal message tends
statement is true regarding this to be the true one because it is under less
situation? The nurse should:
conscious control. Thus studying the nonverbal
a. Ask someone who knows the messages of the patients and examiners and
patient well to help interpret understanding their meanings are important. The
this discrepancy.
other statements are not true.

b. Focus on the patient's verbal

message, and try to ignore the DIF: Cognitive Level: Applying (Application) REF: p.
nonverbal behaviors.
28

c. Try to integrate the verbal MSC: Client Needs: Psychosocial Integrity

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.

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21. During an interview, a parent ANS: D

of a hospitalized child is sitting The person's position is noted. An open position

in an open position. As the with the extension of large muscle groups shows
interviewer begins to discuss relaxation, physical comfort, and a willingness to
his son's treatment, however, he share information. A closed position with the arms
suddenly crosses his arms and legs crossed tends to look defensive and
against his chest and crosses anxious. Any change in posture should be noted. If
his legs. This changed posture a person in a relaxed position suddenly tenses, then
would suggest that the parent this change in posture suggests possible discomfort
is:
with the new topic.

a. Simply changing positions.

b. More comfortable in this DIF: Cognitive Level: Analyzing (Analysis) REF: p. 35

position.
MSC: Client Needs: Psychosocial Integrity
c. Tired and needs a break from
the interview.

d. Uncomfortable talking about

his son's treatment.

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22. A mother brings her 28- ANS: B

month-old daughter into the Although most of the communication is with the
clinic for a well-child visit. At parent, the nurse should not completely ignore the
the beginning of the visit, the child. Making contact will help ease the toddler
nurse focuses attention away later during the physical examination. The nurse
from the toddler, but as the should begin by asking about the toys the child is
interview progresses, the playing with or about a special doll or teddy bear
toddler begins to "warm up" brought from home. "Does your doll have a name?"
and is smiling shyly at the or "What can your truck do?" Stoop down to meet
nurse. The nurse will be most the child at his or her eye level.

successful in interacting with

the toddler if which is done DIF: Cognitive Level: Applying (Application) REF: p.
next?
37

a. Tickle the toddler, and get MSC: Client Needs: Psychosocial Integrity
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.

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23. During an examination of a ANS: D

3-year-old child, the nurse will Take the time to give a short, simple explanation
need to take her blood with a concrete explanation for any unfamiliar
pressure. What might the nurse equipment that will be used on the child.
do to try to gain the child's full Preschoolers are animistic; they imagine inanimate
cooperation?
objects can come alive and have human
a. Tell the child that the blood characteristics. Thus a blood pressure cuff can wake
pressure cuff is going to give up and bite or pinch.

her arm a big hug.

b. Tell the child that the blood DIF: Cognitive Level: Applying (Application) REF: pp.
pressure cuff is asleep and 38-39

cannot wake up.

MSC: Client Needs: Psychosocial Integrity
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.

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24. A 16-year-old boy has just ANS: B

been admitted to the unit for Successful communication with an adolescent is

overnight observation after possible and can be rewarding. The guidelines are
being in an automobile simple. The first consideration is one's attitude, which
accident. What is the nurse's must be one of respect. Second, communication
best approach to must be totally honest. An adolescent's intuition is
communicating with him?
highly tuned and can detect phoniness or the
a. Use periods of silence to withholding of information. Always tell him or her
communicate respect for him.
the truth.

b. Be totally honest with him,

even if the information is DIF: Cognitive Level: Applying (Application) REF: p.
unpleasant.
39

c. Tell him that everything that MSC: Client Needs: Psychosocial Integrity
is discussed will be kept totally
confidential.

d. Use slang language when

possible to help him open up.

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25. A 75-year-old woman is at ANS: A

the office for a preoperative The interview usually takes longer with older adults
interview. The nurse is aware because they have a longer story to tell. It is not
that the interview may take necessarily true that all older adults are lonely, have
longer than interviews with lost mental abilities, or are hard of hearing.

younger persons. What is the

reason for this?
DIF: Cognitive Level: Understanding
a. An aged person has a longer (Comprehension) REF: p. 40

story to tell.
MSC: Client Needs: Psychosocial Integrity
b. An aged person is usually
lonely and likes to have
someone with whom to talk.

c. Aged persons 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.

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26. The nurse is interviewing a ANS: A

male patient who has a hearing The nurse should ask the deaf person the preferred
impairment. What techniques way to communicate—by signing, lip reading, or
would be most beneficial in writing. If the person prefers lip reading, then the
communicating with this nurse should be sure to face him squarely and have
patient?
good lighting on the nurse's face. The nurse should
a. Determine the not exaggerate lip movements because this distorts
communication method he words. Similarly, shouting distorts the reception of a
prefers.
hearing aid the person may wear. The nurse should
b. Avoid using facial and hand speak slowly and supplement his or her voice with
gestures because most appropriate hand gestures or pantomime.

hearing-impaired people find

this degrading.
DIF: Cognitive Level: Understanding
c. Request a sign language (Comprehension) REF: p. 41

interpreter before meeting with MSC: Client Needs: Psychosocial Integrity

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.

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27. During a prenatal check, a ANS: B

patient begins to cry as the A beginning examiner usually feels horrified when
nurse asks her about previous the patient starts crying. When the nurse says
pregnancies. She states that something that "makes the person cry," the nurse
she is remembering her last should not think he or she has hurt the person. The
pregnancy, which ended in nurse has simply hit on an important topic;
miscarriage. The nurse's best therefore, moving on to a new topic is essential. The
response to her crying would nurse should allow the person to cry and to express
be:
his or her feelings fully. The nurse can offer a tissue
a. "I'm so sorry for making you and wait until the crying subsides to talk.

cry!"

b. "I can see that you are sad DIF: Cognitive Level: Applying (Application) REF: p.
remembering this. It is all right 42

to cry."
MSC: Client Needs: Psychosocial Integrity
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?"

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28. A female nurse is ANS: A

interviewing a man who has Both the patient's and the nurse's sense of spatial
recently immigrated. During distance are significant throughout the interview
the course of the interview, he and physical examination, with culturally
leans forward and then finally appropriate distance zones varying widely. Some
moves his chair close enough cultural groups value close physical proximity and
that his knees are nearly may perceive a health care provider who is
touching the nurse's knees. The distancing him or herself as being aloof and
nurse begins to feel unfriendly.

uncomfortable with his

proximity. Which statement DIF: Cognitive Level: Analyzing (Analysis) REF: p. 29

most closely reflects what the MSC: Client Needs: Psychosocial Integrity
nurse should do next?

a. The nurse should try to relax;

these behaviors are culturally
appropriate for this person.

b. The nurse should discreetly

move his or her chair back until
the distance is more
comfortable, and then
continue with the interview.

c. These behaviors are

indicative of sexual aggression,
and the nurse should confront
this person about his behaviors.

d. The nurse should laugh but

tell him that he or she is
uncomfortable with his
proximity and ask him to move
away.

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29. A female American Indian ANS: D

has come to the clinic for Eye contact is perhaps among the most culturally
follow-up diabetic teaching. variable nonverbal behaviors. Asian, American
During the interview, the nurse Indian, Indochinese, Arabian, and Appalachian
notices that she never makes people may consider direct eye contact impolite or
eye contact and speaks mostly aggressive, and they may avert their eyes during the
to the floor. Which statement is interview. American Indians often stare at the floor
true regarding this situation?
during the interview, which is a culturally
a. The woman is nervous and appropriate behavior, indicating that the listener is
embarrassed.
paying close attention to the speaker.

b. She has something to hide

and is ashamed.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 36

c. The woman is showing MSC: Client Needs: Psychosocial Integrity

inconsistent verbal and
nonverbal behaviors.

d. She is showing that she is

carefully listening to what the
nurse is saying.

30. The nurse is performing a ANS: A

health interview on a patient In a situation during which a language barrier exists

who has a language barrier, and no interpreter is available, simple words should
and no interpreter is available. be used, avoiding medical jargon. The use of
Which is the best example of contractions and pronouns should also be avoided.
an appropriate question for the Nouns should be repeatedly used, and one topic at
nurse to ask in this situation?
a time should be discussed.

a. "Do you take medicine?"

b. "Do you sterilize the DIF: Cognitive Level: Analyzing (Analysis) REF: p. 46

bottles?"
MSC: Client Needs: Psychosocial Integrity
c. "Do you have nausea and
vomiting?"

d. "You have been taking your

medicine, haven't you?"

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31. A man arrives at the clinic ANS: D

for his annual wellness physical. Open-ended questions are used for gathering
He is experiencing no acute narrative information. This type of questioning
health problems. Which should be used to begin the interview, to introduce
question or statement by the a new section of questions, and whenever the
nurse is most appropriate when person introduces a new topic.

beginning the interview?

a. "How is your family?" DIF: Cognitive Level: Applying (Application) REF: p.

b. "How is your job?"
31

c. "Tell me about your MSC: Client Needs: Psychosocial Integrity

hypertension."

d. "How has your health been

since your last visit?"

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32. The nurse makes this ANS: C

comment to a patient, "I know it Using authority responses promotes dependency

may be hard, but you should and inferiority. Avoiding the use of authority is best.
do what the doctor ordered Although the health care provider and patient do
because she is the expert in not have equal professional knowledge, both have
this field." Which statement is equally worthy roles in the health process. The other
correct about the nurse's statements are not correct.

comment?

a. This comment is DIF: Cognitive Level: Applying (Application) REF: p.

inappropriate because it shows 34

the nurse's bias.

MSC: Client Needs: Psychosocial Integrity
b. This comment 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.

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33. A female patient does not ANS: A

speak English well, and the Whenever possible, the nurse should use a trained
nurse needs to choose an interpreter, preferably one who knows medical
interpreter. Which of the terminology. In general, an older, more mature
following would be the most interpreter is preferred to a younger, less
appropriate choice?
experienced one, and the same gender is preferred
a. Trained interpreter
when possible.

b. Male family member

c. Female family member

DIF: Cognitive Level: Understanding
d. Volunteer college student (Comprehension) REF: p. 44

from the foreign language MSC: Client Needs: Psychosocial Integrity

studies department

34. During a follow-up visit, the ANS: A

nurse discovers that a patient The adult's use of "why" questions usually implies
has not been taking his insulin blame and condemnation and places the person on
on a regular basis. The nurse the defensive. The other statements are not correct.

asks, "Why haven't you taken

your insulin?" Which statement DIF: Cognitive Level: Analyzing (Analysis) REF: p. 34

is an appropriate evaluation of MSC: Client Needs: Psychosocial Integrity

this question?

a. This question may place the

patient on the defensive.

b. This question is an innocent

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.

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35. The nurse is nearing the ANS: B

end of an interview. Which This question offers the person a final opportunity
statement is appropriate at this for self-expression. No new topic should be
time?
introduced. The other questions are not appropriate.

a. "Did we forget something?"

b. "Is there anything else you DIF: Cognitive Level: Understanding

would like to mention?"
(Comprehension) REF: p. 36

c. "I need to go on to the next MSC: Client Needs: Psychosocial Integrity

patient. I'll be back."

d. "While I'm here, let's talk

about your upcoming surgery."

ANS: D

36. During the interview The interview is the first, and really the most
portion of data collection, the important, part of data collection. During the
nurse collects __________ data.
interview, the nurse collects subjective data; that is,
a. Physical
what the person says about him or herself.

b. Historical

c. Objective
DIF: Cognitive Level: Remembering (Knowledge)
d. Subjective REF: p. 27

MSC: Client Needs: Psychosocial Integrity

ANS: C

37. During an interview, the Social distance, 4 to 12 feet, is usually the distance
nurse would expect that most category for most of the interview. Public distance,
of the interview will take place over 12 feet, is too much distance; the intimate zone
at what distance?
is inappropriate, and the personal distance will be
a. Intimate zone
used for the physical assessment.

b. Personal distance

c. Social distance
DIF: Cognitive Level: Understanding
d. Public distance (Comprehension) REF: p. 29

MSC: Client Needs: Psychosocial Integrity

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38. A female nurse is ANS: D

interviewing a male patient The nurse's response must make it clear that she is a
who is near the same age as health professional who can best care for the
the nurse. During the interview, person by maintaining a professional relationship. At
the patient makes an overtly the same time, the nurse should communicate that
sexual comment. The nurse's he or she accepts the person and understands the
best reaction would be:
person's need to be self-assertive but that sexual
a. "Stop that immediately!"
advances cannot be tolerated.

b. "Oh, you are too funny. Let's

keep going with the interview."
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 42

c. "Do you really think I would MSC: Client Needs: Psychosocial Integrity
be interested?"

d. "It makes me uncomfortable

when you talk that way. Please
stop."

1. The nurse is conducting an ANS: B, C, F

interview. Which of these Open-ended questions allow for self-expression,

statements is true regarding build and enhance rapport, and obtain narrative
open-ended questions? Select information. These features enhance communication
all that apply.
during an interview. The other statements are
a. Open-ended questions elicit appropriate for closed or direct questions.

cold facts.

b. They allow for self- DIF: Cognitive Level: Applying (Application) REF: p.
expression.
31

c. Open-ended questions build MSC: Client Needs: Psychosocial Integrity

and enhance rapport.

d. They leave interactions

neutral.

e. Open-ended questions call

for short one- to two-word
answers.

f. They are used when narrative

information is needed.

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2. The nurse is conducting an ANS: A, D, E

interview in an outpatient clinic The use of a computer can become a barrier. The
and is using a computer to nurse should begin the interview as usual by
record data. Which are the best greeting the patient, establishing rapport, and
uses of the computer in this collecting the patient's narrative story in a direct,
situation? Select all that apply.
face-to-face manner. Only after the narrative is fully
a. Collect the patient's data in a explored should the nurse type data into the
direct, face-to-face manner.
computer. When typing, the nurse should position
b. Enter all the data as the the monitor so that the patient can see it.

patient states them.

c. Ask the patient to wait as the DIF: Cognitive Level: Applying (Application) REF: pp.
nurse enters the data.
30-31

d. Type the data into the MSC: Client Needs: Psychosocial Integrity
computer after the narrative is
fully explored.

e. Allow the patient to see the

monitor during typing.

CHAPTER 4 ...

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1. The nurse is preparing to ANS: D

conduct a health history. Which The purpose of the health history is to collect
of these statements best subjective data—what the person says about him or
describes the purpose of a herself. The other options are not correct.

health history?

a. To provide an opportunity DIF: Cognitive Level: Understanding

for interaction between the (Comprehension) REF: p. 49

patient and the nurse

MSC: Client Needs: Safe and Effective Care
b. To provide a form for Environment: Management of Care
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

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2. When the nurse is evaluating ANS: B

the reliability of a patient's A reliable person always gives the same answers,
responses, which of these even when questions are rephrased or are repeated
statements would be correct? later in the interview. The other statements are not
The patient:
correct.

a. Has a history of drug abuse

and therefore is not reliable.
DIF: Cognitive Level: Applying (Application) REF: p.
b. Provided consistent 49

information and therefore is MSC: Client Needs: Safe and Effective Care
reliable.
Environment: Management of Care
c. Smiled throughout interview
and therefore is assumed
reliable.

d. Would not answer questions

concerning stress and
therefore is not reliable.

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3. A 59-year-old patient tells ANS: D

the nurse that he has ulcerative The reason for seeking care is a brief spontaneous
colitis. He has been having statement in the person's own words that describes
"black stools" for the last 24 the reason for the visit. It states one (possibly two)
hours. How would the nurse signs or symptoms and their duration. It is enclosed
best document his reason for in quotation marks to indicate the person's exact
seeking care?
words.

a. J.M. is a 59-year-old man

seeking treatment for DIF: Cognitive Level: Applying (Application) REF: p.
ulcerative colitis.
50

b. J.M. came into the clinic MSC: Client Needs: Safe and Effective Care
complaining of having black Environment: Management of Care
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.

4. A patient tells the nurse that ANS: A

she has had abdominal pain for A final summary of any symptom the person has
the past week. What would be should include, along with seven other critical
the nurse's best response?
characteristics, "Location: specific." The person is
a. "Can you point to where it asked to point to the location.

hurts?"

b. "We'll talk more about that DIF: Cognitive Level: Applying (Application) REF: p.
later in the interview."
50

c. "What have you had to eat in MSC: Client Needs: Safe and Effective Care
the last 24 hours?"
Environment: Management of Care
d. "Have you ever had any
surgeries on your abdomen?"

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5. A 29-year-old woman tells ANS: D

the nurse that she has The symptom of pain is difficult to quantify because
"excruciating pain" in her back. of individual interpretation. With pain, adjectives
Which would be the nurse's should be avoided and the patient should be asked
appropriate response to the how the pain affects his or her daily activities. The
woman's statement?
other responses are not appropriate.

a. "How does your family react

to your pain?"
DIF: Cognitive Level: Applying (Application) REF: p.
b. "The pain must be terrible. 50

You probably pinched a nerve."

MSC: Client Needs: Safe and Effective Care
c. "I've had back pain myself, Environment: Management of Care
and it can be excruciating."

d. "How would you say the pain

affects your ability to do your
daily activities?"

6. In recording the childhood ANS: D

illnesses of a patient who Childhood illnesses include measles, mumps,

denies having had any, which rubella, chickenpox, pertussis, and strep throat.
note by the nurse would be Avoid recording "usual childhood illnesses" because
most accurate?
an illness common in the person's childhood may be
a. Patient denies usual unusual today (e.g., measles).

childhood illnesses.

b. Patient states he was a "very DIF: Cognitive Level: Remembering (Knowledge)

healthy" child.
REF: p. 51

c. Patient states his sister had MSC: Client Needs: Safe and Effective Care
measles, but he didn't.
Environment: Management of Care
d. Patient denies measles,
mumps, rubella, chickenpox,
pertussis, and strep throat.

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ANS: B

7. A female patient tells the

Obstetric history includes the number of
nurse that she has had six
pregnancies (gravidity), number of deliveries in
pregnancies, with four live
which the fetus reached term (term), number of
births at term and two
preterm pregnancies (preterm), number of
spontaneous abortions. Her
incomplete pregnancies (abortions), and number of
four children are still living.
children living (living). This is recorded: Grav _____
How would the nurse record
Term _____ Preterm _____ Ab _____ Living _____. For any
this information?

incomplete pregnancies, the duration is recorded

a. P-6, B-4, (S)Ab-2

and whether the pregnancy resulted in a

b. Grav 6, Term 4, (S)Ab-2,
spontaneous (S) or an induced (I) abortion.

Living 4

c. Patient has had four living

DIF: Cognitive Level: Applying (Application) REF: p.
babies.

51

d. Patient has been pregnant

MSC: Client Needs: Safe and Effective Care
six times.
Environment: Management of Care

8. A patient tells the nurse that ANS: D

he is allergic to penicillin. What Note both the allergen (medication, food, or

would be the nurse's best contact agent, such as fabric or environmental
response to this information?
agent) and the reaction (rash, itching, runny nose,
a. "Are you allergic to any other watery eyes, or difficulty breathing). With a drug, this
drugs?"
symptom should not be a side effect but a true
b. "How often have you allergic reaction.

received penicillin?"

c. "I'll write your allergy on your DIF: Cognitive Level: Understanding

chart so you won't receive any (Comprehension) REF: p. 52

penicillin."
MSC: Client Needs: Safe and Effective Care
d. "Describe what happens to Environment: Management of Care
you when you take penicillin."

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ANS: C

Questions concerning any family history of heart

9. The nurse is taking a family disease, high blood pressure, stroke, diabetes,
history. Important diseases or obesity, blood disorders, breast and ovarian
problems about which the cancers, colon cancer, sickle cell anemia, arthritis,
patient should be specifically allergies, alcohol or drug addiction, mental illness,
asked include:
suicide, seizure disorder, kidney disease, and
a. Emphysema.
tuberculosis should be asked.

b. Head trauma.

c. Mental illness.
DIF: Cognitive Level: Remembering (Knowledge)
d. Fractured bones. REF: pp. 53-54

MSC: Client Needs: Safe and Effective Care

Environment: Management of Care

ANS: B

10. The review of systems

The purposes of the review of systems are to: (1)
provides the nurse with:

evaluate the past and current health state of each

a. Physical findings related to
body system, (2) double check facts in case any
each system.

significant data were omitted in the present illness

b. Information regarding health
section, and (3) evaluate health promotion
promotion practices.

practices.

c. An opportunity to teach the

patient medical terms.

DIF: Cognitive Level: Remembering (Knowledge)

d. Information necessary for
REF: p. 54

the nurse to diagnose the

MSC: Client Needs: Safe and Effective Care
patient's medical problem.
Environment: Management of Care

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11. Which of these statements ANS: C

represents subjective data the The history should be limited to patient statements
nurse obtained from the or subjective data—factors that the person says
patient regarding the patient's were or were not present.

skin?

a. Skin appears dry.

DIF: Cognitive Level: Understanding
b. No lesions are obvious.
(Comprehension) REF: p. 54

c. Patient denies any color MSC: Client Needs: Safe and Effective Care
change.
Environment: Management of Care
d. Lesion is noted on the lateral
aspect of the right arm.

12. The nurse is obtaining a ANS: A

history from a 30-year-old Health promotion for a man would include the
male patient and is concerned performance of testicular self-examinations. The
about health promotion other questions are asking about possible disease
activities. Which of these or illness issues.

questions would be
appropriate to use to assess DIF: Cognitive Level: Understanding
health promotion activities for (Comprehension) REF: p. 56

this patient?
MSC: Client Needs: Safe and Effective Care
a. "Do you perform testicular Environment: Management of Care
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 diseases?"

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13. Which of these responses ANS: D

might the nurse expect during Functional assessment measures a person's self-care
a functional assessment of a ability in the areas of general physical health or
patient whose leg is in a cast?
absence of illness. The other statements concern
a. "I broke my right leg in a car health or illness issues.

accident 2 weeks ago."

b. "The pain is decreasing, but I DIF: Cognitive Level: Applying (Application) REF: p.
still need to take 56

acetaminophen."
MSC: Client Needs: Safe and Effective Care
c. "I check the color of my toes Environment: Management of Care
every evening just like I was
taught."

d. "I'm able to transfer myself

from the wheelchair to the bed
without help."

14. In response to a question ANS: C

about stress, a 39-year-old Questions about coping and stress management

woman tells the nurse that her include questions regarding the kinds of stresses in
husband and mother both died one's life, especially in the last year, any changes in
in the past year. Which lifestyle or any current stress, methods tried to
response by the nurse is most relieve stress, and whether these methods have
appropriate?
been helpful.

a. "This has been a difficult year

for you."
DIF: Cognitive Level: Applying (Application) REF: p.
b. "I don't know how anyone 57

could handle that much stress MSC: Client Needs: Safe and Effective Care
in 1 year!"
Environment: Management of Care
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."

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15. In response to a question ANS: B

regarding the use of alcohol, a Alcohol adversely interacts with all medications and
patient asks the nurse why the is a factor in many social problems such as child or
nurse needs to know. What is sexual abuse, automobile accidents, and assaults;
the reason for needing this alcohol also contributes to many illnesses and
information?
disease processes. Therefore, assessing for signs of
a. This information is necessary hazardous alcohol use is important. The other
to determine the patient's options are not correct.

reliability.

b. Alcohol can interact with all DIF: Cognitive Level: Understanding

medications and can make (Comprehension) REF: p. 58

some diseases worse.

MSC: Client Needs: Safe and Effective Care
c. The nurse needs to be able Environment: Management of Care
to teach the patient about the
dangers of alcohol use.

d. This information is not

necessary unless a drinking
problem is obvious.

ANS: D

16. The mother of a 16-month-

With a very young child, the parent is asked, "How
old toddler tells the nurse that
do you know the child is in pain?" A young child
her daughter has an earache.
pulling at his or her ears should alert parents to the
What would be an appropriate
child's ear pain. Statements about teething and
response?

questioning whether the child is really having pain

a. "Maybe she is just teething."

do not explore the symptoms, which should be

b. "I will check her ear for an
done before a physical examination.

ear infection."

c. "Are you sure she is really

DIF: Cognitive Level: Applying (Application) REF: p.
having pain?"

59

d. "Describe what she is doing

MSC: Client Needs: Safe and Effective Care
to indicate she is having pain."
Environment: Management of Care

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17. During an assessment of a ANS: B

patient's family history, the A genogram (or pedigree) is a graphic family tree
nurse constructs a genogram. that uses symbols to depict the gender, relationship,
Which statement best and age of immediate blood relatives in at least
describes a genogram?
three generations (parents, grandparents, siblings).
a. List of diseases present in a The other options do not describe a genogram.

person's near relatives

b. Graphic family tree that uses DIF: Cognitive Level: Applying (Application) REF: pp.
symbols to depict the gender, 52-53

relationship, and age of MSC: Client Needs: Safe and Effective Care
immediate family members
Environment: Management of Care
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

18. A 5-year-old boy is being ANS: D

admitted to the hospital to How the child reacted to previous hospitalizations

have his tonsils removed. and any complications should be assessed. If the
Which information should the child reacted poorly, then he or she may be afraid
nurse collect before this now and will need special preparation for the
procedure?
examination that is to follow. The other items are not
a. Child's birth weight
significant for the procedure.

b. Age at which he crawled

c. Whether the child has had DIF: Cognitive Level: Analyzing (Analysis) REF: p. 64

the measles
MSC: Client Needs: Safe and Effective Care
d. Child's reactions to previous Environment: Management of Care
hospitalizations

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19. As part of the health history ANS: B

of a 6-year-old boy at a clinic Because of recent outbreaks of measles across the

for a sports physical United States, the American Academy of Pediatrics
examination, the nurse reviews (2006) recommends two doses of the MMR vaccine,
his immunization record and one at 12 to 15 months of age and one at age 4 to 6
notes that his last measles- years.

mumps-rubella (MMR)
vaccination was at 15 months of DIF: Cognitive Level: Analyzing (Analysis) REF: p. 60

age. What recommendation MSC: Client Needs: Safe and Effective Care
should the nurse make?
Environment: Management of Care
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 years.

d. A recommendation cannot
be made until the physician is
consulted.

20. In obtaining a review of ANS: D

systems on a "healthy" 7-year- When reviewing the cardiovascular system, the

old girl, the health care health care provider should ask whether any activity
provider knows that it would be is limited or whether the child can keep up with her
important to include the:
peers. The other items are not appropriate for a
a. Last glaucoma examination.
child this age.

b. Frequency of breast self-

examinations.
DIF: Cognitive Level: Applying (Application) REF: p.
c. Date of her last 62

electrocardiogram.
MSC: Client Needs: Safe and Effective Care
d. Limitations related to her Environment: Management of Care
involvement in sports activities.

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ANS: C

21. When the nurse asks for a

Functional assessment includes interpersonal
description of who lives with a
relationships and home environment. Family history
child, the method of discipline,
includes illnesses in family members; a review of
and the support system of the
systems includes questions about the various body
child, what part of the
systems; and the reason for seeking care is the
assessment is being
rationale for requesting health care.

performed?

a. Family history

DIF: Cognitive Level: Understanding

b. Review of systems

(Comprehension) REF: p. 63

c. Functional assessment

MSC: Client Needs: Safe and Effective Care

d. Reason for seeking care
Environment: Management of Care

22. The nurse is obtaining a ANS: D

health history on an 87-year- It is important for the nurse to recognize positive

old woman. Which of the health measures, such as what the person has been
following areas of questioning doing to help him or herself stay well and to live to
would be most useful at this an older age. The other responses are not pertinent
time?
to a patient of this age.

a. Obstetric history

b. Childhood illnesses
DIF: Cognitive Level: Applying (Application) REF: p.
c. General health for the past 54

20 years
MSC: Client Needs: Safe and Effective Care
d. Current health promotion Environment: Management of Care
activities

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23. The nurse is performing a ANS: C

review of systems on a 76- The health history includes the same format as that
year-old patient. Which of described for the younger adult, as well as some
these statements is correct for additional questions. These additional questions
this situation?
address ways in which the activities of daily living
a. The questions asked are may have been affected by the normal aging
identical for all ages.
processes or by the effects of chronic illness or
b. The interviewer will start disability.

incorporating different
questions for patients 70 years DIF: Cognitive Level: Understanding
of age and older.
(Comprehension) REF: p. 54

c. Questions that are reflective MSC: Client Needs: Safe and Effective Care
of the normal effects of aging Environment: Management of Care
are added.

d. At this age, a review of

systems is not necessary—the
focus should be on current
problems.

24. A 90-year-old patient tells ANS: D

the nurse that he cannot The person may not know the drug name or
remember the names of the purpose. When this occurs, ask the person or a
medications he is taking or for family member to bring in the drug to be identified.
what reason he is taking them. The other responses would not help to identify the
An appropriate response from medications.

the nurse would be:

a. "Can you tell me what they DIF: Cognitive Level: Applying (Application) REF: p.
look like?"
52

b. "Don't worry about it. You are MSC: Client Needs: Safe and Effective Care
only taking two medications."
Environment: Management of Care
c. "How long have you been
taking each of the pills?"

d. "Would you have a family

member bring in your
medications?"
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25. The nurse is performing a ANS: B

functional assessment on an Functional assessment measures how a person

82-year-old patient who manages day-to-day activities. For the older person,
recently had a stroke. Which of the meaning of health becomes those activities that
these questions would be most they can or cannot do. The other responses do not
important to ask?
relate to functional assessment.

a. "Do you wear glasses?"

b. "Are you able to dress DIF: Cognitive Level: Applying (Application) REF: p.
yourself?"
56

c. "Do you have any thyroid MSC: Client Needs: Safe and Effective Care
problems?"
Environment: Management of Care
d. "How many times a day do
you have a bowel movement?"

26. The nurse is preparing to do ANS: D

a functional assessment. Which The functional assessment measures how a person

statement best describes the manages day-to-day activities. The other answers do
purpose of a functional not reflect the purpose of a functional assessment.

assessment?

a. The functional assessment DIF: Cognitive Level: Remembering (Knowledge)

assesses how the individual is REF: p. 56

coping with life at home.

MSC: Client Needs: Safe and Effective Care
b. It determines how children Environment: Management of Care
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.

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27. The nurse is asking a patient ANS: A

for his reason for seeking care A symptom is a subjective sensation (e.g., chest pain)
and asks about the signs and that a person feels from a disorder. A sign is an
symptoms he is experiencing. objective abnormality that the examiner can detect
Which of these is an example on physical examination or in laboratory reports, as
of a symptom?
illustrated by the other responses.

a. Chest pain

b. Clammy skin
DIF: Cognitive Level: Understanding
c. Serum potassium level at 4.2 (Comprehension) REF: p. 50

mEq/L
MSC: Client Needs: Safe and Effective Care
d. Body temperature of 100 F Environment: Management of Care

28. A patient is describing his ANS: D

symptoms to the nurse. Which The setting describes where the person is or what
of these statements reflects a the person is doing when the symptom starts.
description of the setting of his Describing the pain as "sharp and burning" reflects
symptoms?
the character or quality of the pain; stating that the
a. "It is a sharp, burning pain in pain is "telling" the patient that something bad is
my stomach."
wrong with him reflects the patient's perception of
b. "I also have the sweats and the pain; and describing the "sweats and nausea"
nausea when I feel this pain."
reflects associated factors that occur with the 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."

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29. During an assessment, the ANS: D

nurse uses the CAGE test. The The CAGE test is known as the "cut down, annoyed,
patient answers "yes" to two of guilty, and eye-opener" test. If a person answers
the questions. What could this "yes" to two or more of the four CAGE questions,
be indicating?
then the nurse should suspect alcohol abuse and
a. The patient is an alcoholic.
continue with a more complete substance abuse
b. The patient is annoyed at the assessment.

questions.

c. The patient should be DIF: Cognitive Level: Analyzing (Analysis) REF: p. 58

thoroughly examined for MSC: Client Needs: Safe and Effective Care
possible alcohol withdrawal Environment: Management of Care
symptoms.

d. The nurse should suspect

alcohol abuse and continue
with a more thorough
substance abuse assessment.

30. The nurse is incorporating a ANS: B

person's spiritual values into The "community" is assessed when the nurse asks
the health history. Which of whether a person is part of a religious or spiritual
these questions illustrates the community or congregation. The other areas
"community" portion of the assessed are faith, influence, and addressing any
FICA (faith and belief, religious or spiritual issues or concerns.

importance and influence,

community, and addressing or DIF: Cognitive Level: Understanding
applying in care) questions?
(Comprehension) REF: p. 57

a. "Do you believe in God?"

MSC: Client Needs: Safe and Effective Care
b. "Are you a part of any Environment: Management of Care
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
Health
think aboutAssessment
your health?" Finals Review
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31. The nurse is preparing to ANS: D

complete a health assessment The girl should be interviewed alone. The parents
on a 16-year-old girl whose can wait outside and fill out the family health history
parents have brought her to questionnaires.

the clinic. Which instruction

would be appropriate for the DIF: Cognitive Level: Analyzing (Analysis) REF: p. 64

parents before the interview MSC: Client Needs: Safe and Effective Care
begins?
Environment: Management of Care
a. "Please stay during the
interview; you can answer for
her if she does not know the
answer."

b. "It would help to interview

the three of you together."

c. "While I interview your

daughter, will you please stay
in the room and complete
these family health history
questionnaires?"

d. "While I interview your

daughter, will you step out to
the waiting room and complete
these family health history
questionnaires?"

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32. The nurse is assessing a ANS: B

new patient who has recently Biographic data, such as when the person entered
immigrated to the United the United States and from what country, are
States. Which question is appropriate additions to the health history. The
appropriate to add to the other answers do not reflect appropriate questions.

health history?

a. "Why did you come to the DIF: Cognitive Level: Analyzing (Analysis) REF: p. 54

United States?"
MSC: Client Needs: Psychosocial Integrity
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?"

1. The nurse is assessing a ANS: A, C, D, E

patient's headache pain. Which The mnemonic PQRSTU may help the nurse
questions reflect one or more remember to address the critical characteristics that
of the critical characteristics of need to be assessed: (1) P: provocative or palliative;
symptoms that should be (2) Q: quality or quantity; (3) R: region or radiation;
assessed? Select all that apply.
(4) S: severity scale; (5) T: timing; and (6) U:
a. "Where is the headache understand the patient's perception. Asking, "Where
pain?"
is the pain?" reflects "region." Asking the patient to
b. "Did you have these rate the pain on a 1 to 10 scale reflects "severity."
headaches as a child?"
Asking "How often..." reflects "timing." Asking what
c. "On a scale of 1 to 10, how makes the pain better reflects "provocative." The
bad is the pain?"
other options reflect health history and family
d. "How often do the history.

headaches occur?"

e. "What makes the headaches DIF: Cognitive Level: Analyzing (Analysis) REF: p. 51

feel better?"
MSC: Client Needs: Safe and Effective Care
f. "Do you have any family Environment: Management of Care
history of headaches?"

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2. The nurse is conducting a ANS: B, C, E

developmental history on a 5- Questions about tooth loss, ability to tell time, and
year-old child. Which questions ability to tie shoelaces are appropriate questions for
are appropriate to ask the a developmental assessment. Questions about junk
parents for this part of the food intake and vitamins are part of a nutritional
assessment? Select all that history. Questions about food allergies are not part
apply.
of a developmental history.

a. "How much junk food does

your child eat?"
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 61

b. "How many teeth has he lost, MSC: Client Needs: Safe and Effective Care
and when did he lose them?"
Environment: Management of Care
c. "Is he able to tie his
shoelaces?"

d. "Does he take a children's

vitamin?"

e. "Can he tell time?"

f. "Does he have any food

allergies?"

CHAPTER 5 ...

1. During an examination, the ANS: C

nurse can assess mental status Mental status cannot be directly scrutinized like the
by which activity?
characteristics of skin or heart sounds. Its
a. Examining the patient's functioning is inferred through an assessment of an
electroencephalogram
individual's behaviors, such as consciousness,
b. Observing the patient as he language, mood and affect, and other aspects.

or she performs an intelligence

quotient (IQ) test
PTS: 1 DIF: Cognitive Level: Understanding
c. Observing the patient and (Comprehension)

inferring health or dysfunction

REF: p. 67 MSC: Client Needs: Psychosocial Integrity
d. Examining the patient's
response to a specific set of
questions
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2. The nurse is assessing the ANS: A

mental status of a child. Which Separating and tracing the development of only one
statement about children and aspect of mental status is difficult. All aspects are
mental status is true?
interdependent. For example, consciousness is
a. All aspects of mental status rudimentary at birth because the cerebral cortex is
in children are interdependent.
not yet developed. The infant cannot distinguish the
b. Children are highly labile self from the mother's body. The other statements
and unstable until the age of 2 are not true.

years.

c. Children's mental status is PTS: 1 DIF: Cognitive Level: Understanding

largely a function of their (Comprehension)

parents' level of functioning REF: p. 68 MSC: Client Needs: Psychosocial Integrity

until the age of 7 years.

d. A child's mental status is

impossible to assess until the
child develops the ability to
concentrate.

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3. The nurse is assessing a 75- ANS: C

year-old man. As the nurse The aging process leaves the parameters of mental
begins the mental status status mostly intact. General knowledge does not
portion of the assessment, the decrease, and little or no loss in vocabulary occurs.
nurse expects that this patient:
Response time is slower than in a youth. It takes a
a. Will have no decrease in any little longer for the brain to process information and
of his abilities, including to react to it. Recent memory, which requires some
response time.
processing, is somewhat decreased with aging, but
b. Will have difficulty on tests remote memory is not affected.

of remote memory because

this ability typically decreases PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

with age.
REF: p. 68 MSC: Client Needs: Psychosocial Integrity
c. May take a little longer to
respond, but his general
knowledge and abilities should
not have declined.

d. Will exhibit had a decrease in

his response time because of
the loss of language and a
decrease in general
knowledge.

4. When assessing aging adults, ANS: D

the nurse knows that one of the Age-related changes in sensory perception can
first things that should be affect mental status. For example, vision loss (as
assessed before making detailed in Chapter 14) may result in apathy, social
judgments about their mental isolation, and depression. Hearing changes are
status is:
common in older adults, which produces frustration,
a. Presence of phobias
suspicion, and social isolation and makes the person
b. General intelligence
appear confused.

c. Presence of irrational
thinking patterns
PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

d. Sensory-perceptive abilities REF: p. 68 MSC: Client Needs: Psychosocial Integrity

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5. The nurse is preparing to ANS: B

conduct a mental status The full mental status examination is a systematic

examination. Which statement check of emotional and cognitive functioning. The
is true regarding the mental steps described, however, rarely need to be taken in
status examination?
their entirety. Usually, one can assess mental status
a. A patient's family is the best through the context of the health history interview.

resource for information about

the patient's coping skills.
PTS: 1 DIF: Cognitive Level: Applying (Application)

b. Gathering mental status REF: p. 68 MSC: Client Needs: Psychosocial Integrity

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.

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