Health & Physical Assessment in Nursing, Canadian Edition By Donita T D’Amico – Test Bank
Chapter 10
MULTIPLE CHOICE.
Choose the one alternative that best completes the statement or answers the question. 1) A nurse is interviewing a client and notes a puzzled facial expression. What should the nurse say? 1) “Can you tell me if you understand?” 2) “You look confused.” 3) “Do you understand the procedure?” 4) “Do you have any questions?” 1) 2 Explanation: 1. Closed-ended questions (those that can be answered with one word) do not give any extra information and add little to gathering data. 2. Posture, eye contact, and facial expression add depth to the intended message. The use of open-questions allows the client to elaborate. The nurse is reflecting the non-verbal cues from the client. 3. This is a closed-ended question. 4. This does not indicate that the client appears confused based on the non-verbal. Implementation Analysis Objective – 2 Page – 148 (Table 10.1), 149 Difficulty – 2 2) A nurse is obtaining a family health history when the client reports that a grandparent had Diabetes Mellitus. Where in the health history should the nurse document this information? 1) Health practices 2) Family genogram 3) Past medical history 4) Present health/illness 2) 2 Explanation: 1. Health practices and beliefs about health and illness are important for the nurse to ascertain and are included in a general cultural assessment. 2. A genogram is a representation of family relationships and medical history and is the most effective method of recording large amounts of data gathered from a family’s health history. 3. Past medical history includes any major illness, injuries, hospitalizations, allergies, immunizations, and childhood diseases. 4. Present health/illness includes information about all of the client’s current health-related issues, concerns, and problems as well as the reason for seeking care. Assessment Application Objective – 7 Page – 156 (Table10.2), 161 (Figure 10.4) Difficulty – 1 3) What statement by the nurse would show empathy? 1) “Have you talked this over with your family?” 2) “I’m going to stay with you through the procedure.” 3) “The physician will have to answer that question.” 4) “I understand you’re concerned about your procedure.” 3) 4 Explanation: 1. This statement will help to build a trusting relationship. But it does not demonstrate empathy. 2. This statement shows a willingness to help the client, but is not empathy. 3. This is delaying the client getting information and does not show empathy. 4. Showing understanding and support of the client’s experience or feelings through actions and words demonstrate empathy. Implementation Analysis Objective – 5 Page – 151 Difficulty -2 4) What is a primary source of information the nurse might utilize to collect data? 1) Past medical records 2) The client 3) Family members 4) The physician 4) 2 Explanation: 1. Past medical records are a secondary source. 2. The client is considered the primary source of information. 3. The family is a secondary source. 4. The physician is a secondary source. Assessment Application Objective – 6 Page – 152 Difficulty – 1 5) A nurse is completing the third phase of the health history. What piece of information would the nurse include during this interaction? 1) Biographic data about the client 2) Information about the client’s current health status 3) Data from previous medical records 4) Clarification of previously obtained data 5) 4 Explanation: 1. Biographic data about the client (age, DOB, etc.) is included in the preinteraction phase. 2. Information about why they are seeking care (i.e., what brought them to the healthcare facility) is included in the initial interview phase. 3. Data from previous medical record is included in the preinteraction phase. 4. The purpose of the third phase is to clarify previously obtained assessment data, gather missing information about a specific health concern, update and identify new diagnostic cues as they occur, guide the direction of a physical assessment as it is being conducted, and identify or validate probable nursing diagnoses. Assessment Application Objective – 6 Page – 153, 154, 155 Difficulty – 2 6) A nurse is interviewing an elderly client who has not received a formal high school education. What is the best approach for the nurse to take in this situation? 1) Allow family members to provide the interview information. 2) Develop a new interview format for this client. 3) Adhere to the standard format provided by the facility. 4) Use appropriate words and techniques for this client. 6) 4 Explanation: 1. Family members can provide support, but are not the primary source for information, and clients who are children should be allowed to participate as much as they are able. 2. The nurse would not create a new format. This would be too time consuming. 3. Standard formats provide a guide, but need to be adjusted according to the client’s needs and capabilities. 4. The nurse must consider many aspects of the client and their ability to participate in the interview process such as: culture, language, alterations in senses (blindness, hearing deficits), developmental level, and age. Word usage and overall communication will differ when interviewing children and adolescents or clients with developmental level that differs from the norm. Implementation Analysis Objective – 2 Page – 146 Difficulty – 1 7) Mrs. Nagi, 71 years old, has been readmitted to hospital. She does not speak English. What primary source of information should the nurse use to obtain the health history? 1) Have a translator to assist in talking with Mrs. Nagi. 2) Get the information from a family member. 3) Talk to the nurse who previously cared for Mrs. Nagi. 4) Review Mrs. Nagi’s previous chart. 7) 1 Explanation: 1. The client is a primary source of information. The translator will facilitate communication with Mrs. Nagi. 2. The family is considered to be a secondary source of information. 3. Other health care professionals are considered to be secondary sources of information. 4. Past medical records are a secondary source of information. Assessment Application Objective – 6 Page – 152 Difficulty – 2 8) A client tells the nurse that they have been using herbal remedies to treat their chronic illness. What would be the nurse’s best response? 1) “Tell me what you are taking so I can see if it is appropriate.” 2) “Can you tell me what herbal products you are currently using?” 3) “You should not trust all those remedies.” 4) “It’s great you are trying everything possible to treat your illness.” 8) 2 Explanation: 1. It would be important for the nurse to ascertain what the remedies include, but would it not be appropriate for the nurse to decide their usefulness. 2. As informed consumers, clients are also using a variety of information sources for themselves or family members and are consequently more likely to be informed about recommendations for screening and preventive measures. The nurse needs to ensure the physician has this information to ensure the herbals do not interfere with medications the client may be taking. 3. The nurse should not negate the effect of herbal remedies until the nurse knows what the client is taking and how they are affecting the client. 4. Clients may not be able to judge the reliability of such remedies and may be using products that interfere with their current therapies or are harmful. Implementation Analysis Objective – 8 Page – 159 Difficulty – 1 9) A nurse is obtaining information about a client’s past medical history. What source would begin to provide the nurse with this data? 1) Medication list 2) Lifestyle choices 3) Immunization records 4) Current relationships 9) 3 Explanation: 1. The medication list is related to current history. 2. The description of the client’s health patterns depicts a “lifestyle thread” that allows the nurse to see sets of related traits, habits, or acts that affect the client’s health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined. 3. Past history includes information about childhood diseases, immunizations, allergies, blood transfusions, major illnesses, hospitalizations, labor and deliveries, surgical procedures, mental, emotional or psychiatric health problems, and the use of alcohol, tobacco and other substances. 4. Current relationship information is related to current history. Assessment Application Objective – 7 Page – 159, 160 Difficulty – 2 10) A nurse is interacting with a client and desires to show sensitivity to religious beliefs and customs. Which statement by the nurse would be appropriate during this interaction? 1) “I will tell the hospital Chaplin to see you daily.” 2) “Do you attend church on a regular basis?” 3) “Your amulet cannot be taken to surgery.” 4) “Where would you like to keep your bible?” 10) 4 Explanation: 1. The nurse would not arrange this unless the client has asked for daily visits from the hospital Chaplin. 2. This may be seen as a judgmental question. 3. Arrangements can be made for important religious objects to be taken into surgery. They need to be labeled in the event they become separated from the client. 4. Religious beliefs can influence perceptions about health and illness, and it is important to gain information about customs so the best care can be provided to the client. By allowing the client to have those things that provide meaning and support nearby, the nurse provides spiritual care for the client. Implementation Analysis Objective – 2 Page – 162 Difficulty – 2 11) A nurse is interviewing a client and wants to engage in effective communicating. What technique should the nurse use to decode the client’s messages? 1) Use words and symbols that convey a message 2) Listen actively and attentively 3) Be alert for non-verbal messages 4) Develop and transmit an idea 11) 2 Explanation: 1. Choosing words and symbols to convey a message is the definition of encoding. 2. Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively. 3. Attending is giving full attention to verbal and non-verbal messages. 4. Developing and transmitting an idea is how communication takes place. Implementation Application Objective – 2 Page – 147 Difficulty – 1 12) What is an appropriate opening question to start a health history? 1) “What is your current occupation?” 2) “What led up to you seeking help with your health?” 3) “What medications are you currently taking?” 4) “What surgeries have you had?” 12) 2 Explanation: 1. Asking personal questions may cause the client to shut down and given less information. 2. The opening questions are purposely broad and vague to let the client adjust to the questioning nature of the interview. 3. This is a personal question and opening questions should be broad and vague to allow the client adjust. 4. This is a specific question and the opening questions should be broad and vague. Implementation Analysis Objective – 2 and 6 Page – 154 Difficulty – 2 13) A nurse is interviewing a client who is in acute pain. What action would be the best choice for the nurse during this interview? 1) Interview the family for the information 2) Attempt to reduce the pain and complete the interview later 3) Document why the interview could not be completed 4) Ask the client if they can complete the interview 13) 2 Explanation: 1. Although secondary sources (family members, the medical record, and other members of the healthcare team) can be used to gather data, the client provides the primary information and should be the first choice for data assessment when possible. 2. The ability to participate in an interview is diminished when the client is experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain, and gather in-depth information at another time. 3. Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data. 4. The client will not be able to concentrate and provide as in-depth information as possible if experiencing pain; regardless of how fast or slow the process takes. Implementation Analysis Objective – 6 Page – 154 Difficulty – 2 14) A nurse is preparing to do a health history on a client. What would be most appropriate in planning for the interview? 1) Stand at the bedside to conduct the interview 2) Sit about 0.25 meters away from the client. 3) Provide water and tissues for the client. 4) Conduct the interview in the lounge provided for clients 14) 4 Explanation: 1. The nurse should be at the same height as the client. If the nurse is standing or sitting higher than the client it may make the client uncomfortable. 2. The nurse should sit about 0.5 to 2.0 meters away from the client. This prevents the nurse from getting into the client’s personal space. 3. Providing the client with water and tissues allows the client to take sips while answering questions. The tissues may be required if some questions cause the client to weep. 4. The interview should be conducted in private. If it is done at the bedside then the nurse should use a soft voice. Assessment Analysis Objective – 6 Page – 153 Difficulty – 2 15) A client is prescribed the use of a machine to aid with sleep apnea but doesn’t want to use it. What response by the nurse would aid in determining the client’s reluctance to use prescribed medical treatment? 1) “I guess the machine is complicated to use.” 2) “You’re not alone; many clients don’t use their sleep apnea machines.” 3) “I’m sure your doctor will figure something out about your sleep apnea.” 4) “Tell me what you think about the machine.” 15) 4 Explanation: 1. The nurse should not assume that the client doesn’t know how to use the machine. 2. The nurse should not assume that many clients do not use the same machine. 3. The nurse shouldn’t transfer the client’s non-adherence to prescribed medical treatment on the physician. 4. The best response for the nurse to make is to assess why the client doesn’t want to use the machine. This will help the nurse determine the support and teaching the client will need. Planning Application Objective – 2 Page – 146, 147, 148 (Table 10.1) Difficulty – 2 16) A nurse says to a client, “It sounds like you don’t like your new job because it’s more stressful than you anticipated.” What communication technique is the nurse using? 1) Listening 2) Paraphrasing 3) Questioning 4) Attending 16) 2 Explanation: 1. Listening is paying undivided attention to what the client says and does. 2. Paraphrasing is restating the client’s basic message to test if it was understood. 3. Questioning is the use of questions to gain insight. 4. Attending is providing the client with undivided attention. Assessment Application Objective – 2 Page – 148 (Table 10.1) Difficulty – 1 17) A client tells the nurse about two abortions she had while in university. The nurse responds, “What university did you go to?” This response is evidence of which type of barrier to communication? 1) Cross-examination 2) Changing the subject 3) False reassurance 4) Use of technical terms 17) 2 Explanation: 1. Cross-examination is when questions are repeatedly directed to a client causing the client to feel threatened. 2. This nurse is changing the subject which shows insensitivity to the client’s thoughts and feelings. This happens when the nurse is not at ease with the client’s comments and is unable to deal with the content. 3. False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it. 4. Use of technical terms is when the nurse uses terms or jargon specific to the medical field. Assessment Application Objective – 3 Page – 149 Difficulty – 1 18) The nurse is assessing a client through the use of an interpreter. After one response, the interpreter says to the nurse, “I think she’s really sick but doesn’t want to tell you.” How should the nurse respond to the interpreter? 1) Ask the interpreter to ask the client, “What other health issues have you been experiencing?” 2) “Tell me why you think that.” 3) “Are you sure? She hasn’t said anything to me.” 4) “I think so too, especially when she wouldn’t answer my one question about pain and sleeping.” 18) 1 Explanation: 1. The nurse should ask the interpreter to ask the client about other health issues. 2. It is important to avoid discussing the client with the translator, leaving the client out of the conversation. 3. The nurse should not argue with the interpreter while the interview is in progress. 4. The nurse should not discuss the client with the interpreter. Assessment Analysis Objective – 4 Page – 150, 151 (Box 10-1) Difficulty – 2 19) While conducting a health history, the nurse stands and uses the examination room sink to document client information. Afterwards the nurse states, “The doctor will be in to see you in a few minutes,” and leaves the room. What is the nurse demonstrating to the client? 1) Concreteness 2) A lack of genuineness 3) Positive regard 4) Empathy 19) 2 Explanation: 1. Concreteness means speaking to the client in specific terms instead of vague generalities. 2. Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. Her non-verbal communication may indicate a distancing from the client. 3. Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude. 4. Empathy is the capacity to respond to another’s feelings and experiences as if they were your own. Assessment Analysis Objective – 5 Page – 151 Difficulty – 2 20) A client comes into the Emergency Department speaking incoherently. What should the nurse do to obtain information about the client’s current health status? 1) Talk with the immediate family members who brought the client to the hospital. 2) Call the Medical Records department to obtain other records for the client. 3) Call the client’s physician. 4) Conduct a thorough physical assessment and document the health history as unable to obtain. 20) 1 Explanation: 1. The primary and best source of information for the health assessment interview is the client. In some situations, the client might be unwilling or unable to provide information. The nurse should use another source of information if indicated. This client is incoherent and is accompanied by family members. The nurse should talk with the family members. 2. Calling Medical Records for other admission information might be appropriate at a later time. 3. Phoning the physician might be appropriate at a later time. 4. The nurse should not document the health history as unable to obtain since family members are available to provide this information. Planning Analysis Objective – 8 Page – 152 Difficulty – 3 21) A nurse says to a client, “Before we provide any care to you, I will need to spend about 30 minutes talking about your current problem and any other health issues that might impact how you are feeling right now.” In which phase of the health assessment interview is the nurse participating? 1) Closure of the Interview 2) The Initial Interview 3) The Clarification Interview 4) Preinteraction 21) 2 Explanation: 1. There is no specific phase termed “closure of the interview.” This nurse is conducting the initial interview with this client. 2. The initial interview occurs when the nurse uses a period of time to talk with the client and document any information that would aid in care for the current health issue. 3. There is no clarification interview. 4. Preinteraction is when the nurse prepares to meet the client and reviews any available background information. Implementation Application Objective – 6 Page – 154 Difficulty – 1 22) A nurse is conducting a psychosocial history with a client. What question would be included in this assessment? 1) Have you noticed any change in your vision? 2) Are you the head of your family? 3) Have you had any major surgeries? 4) How long have you worked for your current employer? 22) 4 Explanation: 1. Assessment of vision would be included in the Review of Body Systems. 2. This is part of biographical data. 3. Surgical history is a part of medical history. 4. Elements of the Psychosocial History within the Health History include occupational history, education, financial background, roles and relationships, family, social structure/emotional concerns, and self-concept. Implementation Application Objective – 7 Page – 156 (Table 10.2), 161 Difficulty -1 23) During the course of a health history the nurse would like to review a client’s medications. What should the nurse include in the assessment? 1) The place in the home where the medications are stored. 2) List of all the medication the client has ever been prescribed. 3) List of all over-the-counter and herbal preparations the client is taking. 4) The number of dosages left for each medication the client is taking. 23) 3 Explanation: 1. Where in the home the medications are stored is not part of the medication history. 2. The medication history is limited to the medications and herbals the client is currently taking. 3. Information about medications should include all prescribed and over the counter medications. The use of home remedies, folk remedies, herbs, teas, vitamins, dietary supplements or other substances should also be listed. 4. It is unlikely the client would know this and it is not part of the medication history. Implementation Application Objective – 7 Page – 159 Difficulty – 2 24) During the assessment of an elderly female from another cultural group, the client says, “Please call my husband in. I want him in the room with me.” What should the nurse do in response to this client’s request? 1) Escort the husband into the room. 2) Document that the client refuses the assessment. 3) Ask the client to wait a few minutes until the assessment is completed. 4) Ask another nurse to assist with the assessment. 24)1 Explanation: 1. The nurse should respect the wishes of the client and the client’s culture by requesting the presence of the husband in the room. 2. The client is not refusing the assessment and should not be documented as such. 3. The nurse should not ask the client to wait until the assessment is completed. 4. The nurse should not ignore the client’s request. Implementation Analysis Objective – 4 Page – 161, 162 Difficulty – 2 25) What is helpful when communicating with a client who does not speak English? 1) Sit facing the translator and client 2) Discuss each question and answer with the translator 3) Use a member of the client’s family to translate 4) Look at the client while telling the translator what to say 25) 4 Explanation 1. The nurse should sit with the translator facing the client. If the client is very anxious the translator might sit beside the client. 2. The nurse should refrain from having a discussion with the translator. The translator should only translate what is said by the nurse and the client. 3. Official translators should be used whenever possible. They understand the medical terminology and can translate what the nurse states. 4. The nurse is talking with the client and thus should look at the client when asking questions, even when a translator is used. Implementation Application Objective – 2 Page – 150, 151 (Box 10.1) Difficulty – 2 26) What is a genogram? 1) Depiction of a client’s support systems. 2) Representation of family relationships. 3) Pictorial of family relationships and health history. 4) Graphical display of all system’s in a client’s life. 26) 3 Explanation 1. A genogram depicts a client’s family relationships and health history. 2. The genogram does more then depict family relationships. It also depicts each family member’s healthy history. 3. A genogram is a picture of family relationships and health history. 4. This is an ecomap. Assessment Application Objective – 9 Page – 161 Difficulty – 1 27) Mrs. Matthews, 63 years old, tells the nurse she was a social drinker. What should the nurse do next? 1) Document that Mrs. Matthews does not drink alcohol. 2) Ask what she currently drinks at social gatherings. 3) Inquire whether Mrs. Matthews smokes. 4) Ask Mrs. Matthews how many drinks she had per week. 27) 4 Explanation 1. The nurse should document this but needs to determine how much the Mrs. Matthews drank and for how many years. 2. The nurse needs to determine what ‘social drinking’ means to Mrs. Matthews. She has already stated she no longer drinks alcohol. 3. Before moving on to another topic the nurse needs to determine what social drinking means to Mrs. Matthews. 4. The nurse needs to determine how much Mrs. Matthews drank and for how long. Assessment Application Objective – 8 Page – 160 Difficulty – 3 28) What is the purpose of a health history? 1) Gather data about the cause of the health problem 2) Document responses to potential and actual health concerns 3) Collect objective data about the current health problem 4) Document findings from a physical assessment 28) 2 Explanation 1. This is the focus of the medical history taken by the physician. 2. The health history is a comprehensive record of the client’s past and present health. The focus is on the client’s response to a health concern as a whole person. 3. The health history is subjective data about the client’s current and past health. 4. The physical examination occurs after the health history has been taken. Knowledge Application Objective – 1 Page – 146, 155 Difficulty – 1 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 29) While observing a nurse interacting with a client, the nursing student notes that the client will not talk with anyone in the room. Which comment by the nurse would have been non-therapeutic or harmful in this interaction and could have facilitated this silence from the client? (Select all that apply.) _______“I’m not sure what time the procedure will be, but I will check for you.” _______“I’ll try to explain things before they happen to you.” _______“You shouldn’t feel scared; there is nothing to worry about.” _______“Let’s not talk about your surgery now; it will only make you worry.” 29) _______“I’m not sure what time the procedure will be, but I will check for you.” _______“I’ll try to explain things before they happen to you.” ___X__ “You shouldn’t feel scared; there is nothing to worry about.” ___X__ “Let’s not talk about your surgery now; it will only make you worry.” Explanation: Non-therapeutic interactions interfere with the communication process by making the client uncomfortable, anxious, or insecure, and these include giving false reassurances, passing judgment, changing the subject, cross-examination, use of technical terms, and insensitivity. Therapeutic communication techniques include being honest and straightforward with responses. Implementation Analysis Objective – 3 Page – 149, 150 Difficulty – 2
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