Chapter 10 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 10

Question 1

Type: MCMA

The student nurse is preparing to perform a health history interview. Which of the following statements indicate that the student nurse requires further education regarding the purpose of the health history?

Standard Text: Select all that apply.

1. As the nurse, I will mainly focus on the course of the clients illness.

2. The clients health history can be gathered during the initial interview.

3. I realize that the client is sick, but I also need to perform a wellness assessment.

4. The healthcare providers and nurses assessments should be almost identical with the same focus.

5. The nurse typically has a more holistic point of view regarding the clients health.

Correct Answer: 1,4

Rationale 1: As the nurse, I will mainly focus on the course of the clients illness. The healthcare provider will typically focus on the clients illness, while the nurse will focus on the client.

Rationale 2: The clients health history can be gathered during the initial interview. The nurse can gather the health history during the initial interview.

Rationale 3: I realize that the client is sick, but I also need to perform a wellness assessment. The nurse should perform a wellness assessment as part of the health history.

Rationale 4: The healthcare providers and nurses assessments should be almost identical with the same focus. The healthcare providers focus and the nurses focus regarding the clients health differ significantly. The nurses health history may produce information about a medical diagnosis, but the focus is on the clients response to the health concern as a whole person. The healthcare provider focuses on specific body systems or body parts of the client.

Rationale 5: The nurse typically has a more holistic point of view regarding the clients health. The nurse does typically have a more holistic view of the client when compared to the healthcare providers point of view.

Global Rationale: The healthcare provider will typically focus on the clients illness, while the nurse will focus on the client. The healthcare providers focus and the nurses focus regarding the clients health differ significantly. The nurses health history may produce information about a medical diagnosis, but the focus is on the clients response to the health concern as a whole person. The healthcare provider focuses on specific body systems or body parts of the client. The nurse can gather the health history during the initial interview. The nurse should perform a wellness assessment as part of the health history. The nurse does typically have a more holistic view of the client when compared to the healthcare providers point of view.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.1: Discuss the purpose of the nursing health history.

Question 2

Type: MCMA

The client has been diagnosed with an early stage of wide-angle glaucoma. The nurse is performing a wellness assessment during the clients initial interview. Which of the following statements by the client may be elicited during this portion of the health history?

Standard Text: Select all that apply.

1. My mom was diagnosed with glaucoma when she was 60 years old.

2. I pay attention to the foods that I eat, because I want my body to stay well.

3. I think I do a good job of managing stress with yoga every day and running three times a week.

4. My husband and I have 3 couples that we would classify as our very good friends.

5. Sometimes, my eyes feel very tired and sort of ache.

Correct Answer: 2,3,4

Rationale 1: My mom was diagnosed with glaucoma when she was 60 years old. The nurse should ask about the clients family history at some point during the health history but not during the wellness assessment.

Rationale 2: I pay attention to the foods that I eat, because I want my body to stay well. The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is nourishing the body during the wellness assessment.

Rationale 3: I think I do a good job of managing stress with yoga every day and running three times a week. The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is managing stress during the wellness assessment.

Rationale 4: My husband and I have 3 couples that we would classify as our very good friends. The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how well the client is interacting socially during the wellness assessment.

Rationale 5: Sometimes, my eyes feel very tired and sort of ache. The nurse should ask about the clients symptoms related to the condition but not during the wellness assessment.

Global Rationale: The wellness assessment portion of the health history is designed to determine how the client optimizes health and well-being. The nurse should determine how the client is nourishing the body, managing stress, and interacting socially. The client was diagnosed with glaucoma. Information about the clients eyes may be gathered as the nurse focuses on the clients health concerns or illness. The nurse should ask about the clients family history at some point during the health history but not during the wellness assessment. The nurse should ask about the clients symptoms related to the condition but not during the wellness assessment.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.1: Discuss the purpose of the nursing health history.

Question 3

Type: MCMA

While interviewing the client during the focused interview, the client begins to cry softly. Which of the following interventions by the nurse are appropriate?

Standard Text: Select all that apply.

1. The nurse states, Its all right, I think were done with the interview.

2. The nurse places the tissues within arms reach of the client.

3. The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview.

4. The nurse states, I dont like these questions any more than you do, but we need to get on with the interview so you can go home and cry later.

5. The nurse states, I can see you are upset. Its all right to cry.

Correct Answer: 2,3,5

Rationale 1: The nurse states, Its all right, I think were done with the interview. It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning.

Rationale 2: The nurse places the tissues within arms reach of the client. When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client.

Rationale 3: The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview. It is appropriate for the nurse to remain quiet while the client cries.

Rationale 4: The nurse states, I dont like these questions any more than you do, but we need to get on with the interview so you can go home and cry later. It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad.

Rationale 5: The nurse states, I can see you are upset. Its all right to cry. The nurse should not hurry the interview along or not provide time for the client to display emotion.

Global Rationale: When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client. It is appropriate for the nurse to remain quiet while the client cries. It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad. It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning. The nurse should not hurry the interview along or not provide time for the client to display emotion.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history.

Question 4

Type: MCMA

The nurse recently gave birth to a stillborn infant. During the preinteraction stage, the nurse learns that the client has had 5 elective abortions performed while she was in high school and college. Which of the following nursing actions are appropriate to help the nurse prepare emotionally for the initial interview with this client?

Standard Text: Select all that apply.

1. The nurse speaks with one of her nursing peers and sets up a time to role-play the interview.

2. The nurse writes in her journal regarding her fears about meeting with the client.

3. The nurse makes an appointment to meet with her counselor prior to the interview.

4. The nurse should remain very quiet during the interview so that the initial interview will only last for a brief time.

5. The nurse creates a list of her own goals to accomplish during the interview with this client.

Correct Answer: 1,2,3,5

Rationale 1: The nurse speaks with one of her nursing peers and sets up a time to role-play the interview. The nurse should speak with one of her nursing peers to role-play how the interview may proceed.

Rationale 2: The nurse writes in her journal regarding her fears about meeting with the client. The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client.

Rationale 3: The nurse makes an appointment to meet with her counselor prior to the interview. The nurse can make an appointment to speak with her counselor about her feelings prior to the interview.

Rationale 4: The nurse should remain very quiet during the interview so that the initial interview will only last for a brief time. The nurse will not be able to elicit an adequate amount of information from the client if she is focusing only on being quiet during the interview.

Rationale 5: The nurse creates a list of her own goals to accomplish during the interview with this client. The nurse can create a list of goals to accomplish during the interview.

Global Rationale: The nurse should speak with one of her nursing peers to role-play how the interview may proceed. The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client. The nurse can make an appointment to speak with her counselor about her feelings prior to the interview. The nurse can create a list of goals to accomplish during the interview. The nurse will not be able to elicit an adequate amount of information if she is focusing only on being quiet during the interview.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history.

Question 5

Type: MCMA

The student nurse and the experienced nurse are meeting with an elderly Vietnamese client who is unable to speak English. Which of the following actions indicate that the student nurse requires further education?

Standard Text: Select all that apply.

1. The student nurse looks intently at the translator during the interview.

2. The student nurse is sitting directly beside the client and both of them are facing the translator.

3. The student nurse asks one question at a time.

4. The student nurse has requested that the client bring his daughter to the interview to translate for him.

5. The student nurse states, Please tell him to void in this specimen container and to use a clean-catch technique when acquiring the urine.

Correct Answer: 1,2,4,5

Rationale 1: The student nurse looks intently at the translator during the interview. The student nurse should look at the client during the interview, not at the translator.

Rationale 2: The student nurse is sitting directly beside the client and both of them are facing the translator. The student nurse should across from the client. The translator should sit next to the client.

Rationale 3: The student nurse asks one question at a time. The student nurse should ask one question at a time.

Rationale 4: The student nurse has requested that the client bring his daughter to the interview to translate for him. The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation.

Rationale 5: The student nurse states, Please tell him to void in this specimen container and to use a clean-catch technique when acquiring the urine. The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well.

Global Rationale: The student nurse should look at the client during the interview, not at the translator. The student nurse should sit across from the client. The translator should sit next to the client. The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation. The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well. The student nurse should ask one question at a time.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history.

Question 6

Type: MCSA

The nurse is interviewing the client. The nurse states, Can you tell me exactly how you feel when you are having difficulty catching your breath? Which of the following types of communication techniques is the nurse utilizing specifically?

1. Focusing

2. Attending

3. Paraphrasing

4. Summarizing

Correct Answer: 1

Rationale 1: Focusing is used to help the client zero in on a subject or get in touch with feelings.

Rationale 2: Attending is when the nurse gives the client undivided attention.

Rationale 3: Paraphrasing or clarifying is when the nurse restates the clients basic message to test whether it was understood.

Rationale 4: Summarizing is when the nurse ties together the various messages that the client has communicated throughout the interview.

Global Rationale: Focusing is used to help the client zero in on a subject or get in touch with feelings. Attending is when the nurse gives the client undivided attention. Paraphrasing or clarifying is when the nurse restates the clients basic message to test whether it was understood. Summarizing is when the nurse ties together the various messages that the client has communicated throughout the interview.

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history.

Question 7

Type: MCSA

The nurse is interviewing the client. The nurse says to the client, It sounds like you dont like your new job because its more stressful than you anticipated. Which of the following types of communication techniques is the nurse utilizing specifically?

1. Listening

2. Attending

3. Questioning

4. Paraphrasing

Correct Answer: 4

Rationale 1: Listening is paying undivided attention to what the client says and does.

Rationale 2: Giving full attention to verbal and nonverbal messages is called attending. Body language may be as much as 93% of the message a client sends.

Rationale 3: Questioning is a very direct way of speaking with clients to obtain subjective data for decision making and planning care. Questioning techniques include closed and open-ended questions.

Rationale 4: Communication skills include checking to make sure that the nurse has understood the client accurately by paraphrasing. Paraphrasing, or clarification, means that the nurse restates the clients basic message back to the client to ensure that the nurse understood the clients message correctly.

Global Rationale: Communication skills include checking to make sure that the nurse has understood the client accurately by paraphrasing. Paraphrasing, or clarification, means that the nurse restates the clients basic message back to the client to ensure that the nurse understood the clients message correctly. Listening is paying undivided attention to what the client says and does. Giving full attention to verbal and nonverbal messages is called attending. Body language may be as much as 93% of the message a client sends. Questioning is a very direct way of speaking with clients to obtain subjective data for decision making and planning care. Questioning techniques include closed and open-ended questions.

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history.

Question 8

Type: MCSA

The nurse is interviewing the client. Which of the following techniques should the nurse use to decode the clients messages?

1. Listen actively and attentively.

2. Develop and transmit an idea.

3. Use words to convey the message.

4. Use body language to convey the message.

Correct Answer: 1

Rationale 1: Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively.

Rationale 2: Developing and transmitting an idea is how communication takes place.

Rationale 3: Choosing words to convey a message is the definition of encoding.

Rationale 4: Displaying body language to convey a message is the definition of encoding.

Global Rationale: Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively. Developing and transmitting an idea is how communication takes place. Choosing words and symbols to convey a message is the definition of encoding. Displaying body language to convey a message is the definition of encoding.

Cognitive Level: Remembering

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.2: Describe communication skills used by the professional nurse when conducting a health history.

Question 9

Type: MCSA

A client tells the nurse about two abortions she had while in college. The nurse responds, What did you major in while you were in college? This response is evidence of which type of barrier to communication?

1. Changing the subject

2. False reassurance

3. Cross-examination

4. Use of technical terms

Correct Answer: 1

Rationale 1: This is an example of changing the subject. This nurse is changing the subject, which shows insensitivity to the clients thoughts and feelings. This happens when the nurse is not at ease with the clients comments and is unable to deal with the content.

Rationale 2: False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it.

Rationale 3: Cross-examination is when questions are repeatedly directed to a client, causing the client to feel threatened.

Rationale 4: Use of technical terms is when the nurse uses terms that are specific to the medical field.

Global Rationale: This is an example of changing the subject. This nurse is changing the subject, which shows insensitivity to the clients thoughts and feelings. This happens when the nurse is not at ease with the clients comments and is unable to deal with the content. False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it. Cross-examination is when questions are repeatedly directed to a client causing the client to feel threatened. Use of technical terms is when the nurse uses terms that are specific to the medical field.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.3: Identify barriers to effective nurse-client communication

Question 10

Type: MCSA

The nurse is interviewing a client who is in acute pain. Which of the following actions by the nurse must be performed first?

1. Interview the family for the information.

2. Attempt to reduce the pain and complete the interview later.

3. Proceed very quickly with the interview.

4. Document why the interview could not be completed.

Correct Answer: 2

Rationale 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.

Rationale 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 then gather in-depth information at another time.

Rationale 3: 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.

Rationale 4: Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data.

Global Rationale: 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 then gather in-depth information at another time. 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. 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. Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.3: Identify barriers to effective nurse-client communication.

Question 11

Type: MCSA

The nurse is admitting a young client of Cuban descent to the hospital. The nurse responds in a culturally sensitive manner by choosing which of the following actions?

1. Allowing all family members to be present during the admission

2. Ensuring that the father of the young client is provided with adequate amounts of information regarding the young clients care

3. Requesting that all family members wait in the waiting room

4. Ensuring that the mother of the young client is provided with adequate amounts of information regarding the young clients care

Correct Answer: 2

Rationale 1: The head of the Cuban household is the male. The clients father should be recognized as the decision maker in this family.

Rationale 2: The head of the Cuban household is the male. The clients father will most likely make decisions regarding the young clients care.

Rationale 3: The head of the Cuban household is the male. The clients father should be recognized as the decision maker in this family.

Rationale 4: Native American groups look to mothers and grandmothers to make healthcare decisions. In Filipino households the authority in the family is shared, yet the decisions related to health care are made mostly by the women. The head of the Cuban household is the male. The father should be included when providing care for the young client.

Global Rationale: The head of the Cuban household is the male. The father should be provided with appropriate information regarding the young clients care. The clients father will most likely make decisions regarding the young clients care. Native American groups look to mothers and grandmothers to make healthcare decisions. In Filipino households the authority in the family is shared, yet the decisions related to health care are made mostly by the women. Determination of roles and relationships is important when planning health care and assisting the client to make healthcare decisions, and the nurse should be prepared to include recognized decision makers in the planning process.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.4: Describe the influence of culture on nurse-client interactions.

Question 12

Type: SEQ

The nurse is preparing to interview the client during the initial interview. Rank the following nursing statements in order of their most likely occurrence.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Were almost done; do you have any questions for me?

Choice 2. May I call you Anne?

Choice 3. When you said you had been having trouble with your belly, what did you mean?

Choice 4. So, can you tell me about whats been going on with your health?

Correct Answer: 2,4,3,1

Rationale 1: The nurse should then close the interview by allowing the client to ask questions.

Rationale 2: The nurse should first greet the client and ask if it is all right to call the client by her first name.

Rationale 3: The nurse should ask questions to clarify information given by the client during the interview.

Rationale 4: The nurse should initially ask generalized open-ended questions about the clients health status.

Global Rationale: The nurse should greet the client and ask if it is all right to call the client by her first name. The nurse should initially generalized open-ended questions about the clients health status. The nurse should ask questions to clarify information given by the client during the interview. The nurse should then close the interview by allowing the client to ask questions.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.4: Describe the influence of culture on nurse-client interactions.

Question 13

Type: MCSA

While conducting the clients health history, the nurse makes little eye contact with the client and focuses intently upon the computer while documenting the clients information. The nurse faces the computer with legs crossed. Of the following types of nursing behaviors, which is most appropriate way to describe this situation?

1. A lack of empathy

2. A lack of genuineness

3. A lack of concreteness

4. A lack of positive regard

Correct Answer: 2

Rationale 1: Empathy is the capacity to respond to anothers feelings and experiences as if they were your own. To a lesser extent, the nurse is displaying a lack of empathy by not communicating well with the client.

Rationale 2: Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial expressions appropriate to the situation, and open body language. Facing the client, leaning forward during conversation, and sitting with arms and legs uncrossed are examples of open body language.

Rationale 3: Concreteness means speaking to the client in specific terms instead of vague generalities. The nurse isnt necessarily providing vague information for the client.

Rationale 4: Positive regard is the ability to appreciate and respect another persons worth and dignity with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse is demonstrating a lack of positive regard.

Global Rationale: Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial expressions appropriate to the situation, and open body language. Facing the client, leaning forward during conversation, and sitting with arms and legs uncrossed are examples of open body language. Empathy is the capacity to respond to anothers feelings and experiences as if they were your own. To a lesser extent, the nurse is displaying a lack of empathy by not communicating well with the client. Concreteness means speaking to the client in specific terms instead of vague generalities. The nurse isnt necessarily providing vague information for the client. Positive regard is the ability to appreciate and respect another persons worth and dignity with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse is demonstrating a lack of positive regard.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.5: Discuss the professional characteristics used in establishing a nurse-client relationship.

Question 14

Type: MCMA

The nurse is performing a focused interview with the client. Which of the following behaviors indicate that the client may be feeling anxious?

Standard Text: Select all that apply.

1. While seated, the client begins to wiggle his foot back and forth quickly.

2. The client leans back in his chair and seems to move away from the nurse.

3. The client crosses his arms and becomes very quiet.

4. The client leans forward in the chair and uncrosses his legs.

5. The client seems to be distracted and is no longer making direct eye contact with the nurse.

Correct Answer: 1,2,3,5

Rationale 1: While seated, the client begins to wiggle his foot back and forth quickly. If the client seems restless, this can indicate that the client is anxious.

Rationale 2: The client leans back in his chair and seems to move away from the nurse. The client who leans back in his chair may be anxious and feels invaded by the nurses questions.

Rationale 3: The client crosses his arms and becomes very quiet. The client who crosses his arms is expressing anxiety.

Rationale 4: The client leans forward in the chair and uncrosses his legs. The client who leans forward in his chair and uncrosses his arms is not displaying anxiety. This behavior indicates that the client is preparing to open up.

Rationale 5: The client seems to be distracted and is no longer making direct eye contact with the nurse. The client who seems distracted may be disengaging from the nurses interview due to anxiety.

Global Rationale: If the client seems restless, this can indicate that the client is anxious. The client who leans back in his chair may be anxious and feels invaded by the nurses questions. The client who crosses his arms is expressing anxiety. The client who seems distracted may be disengaging from the nurses interview due to anxiety. The client who leans forward in his chair and uncrosses his arms is not displaying anxiety. This behavior indicates that the client may be preparing to open up with the nurse.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.6: Discuss the phases of the client interview.

Question 15

Type: MCMA

The nurse is preparing to interview the hospitalized client. Which of the following statements by the clients nurse indicates that the interview should be postponed?

Standard Text: Select all that apply.

1. I cant seem to get her pain under control this morning.

2. I just gave her morphine sulfate through her IV for pain about 20 minutes ago.

3. She was anxious earlier and received some lorazepam.

4. Shes been oriented to self only since admission.

5. I gave her some ibuprofen about 1 hour ago.

Correct Answer: 1,2,3,4

Rationale 1: I cant seem to get her pain under control this morning. The nurse should postpone the interview if the client is in pain.

Rationale 2: I just gave her morphine sulfate through her IV for pain about 20 minutes ago. The interview should be postponed if the client received opioid pain medications because it may alter the ability for the client to adequately answer the nurses questions.

Rationale 3: She was anxious earlier and received some lorazepam. The nurse should postpone the interview if the client was given lorazepam because it can sedate the client.

Rationale 4: Shes been oriented to self only since admission. The nurse should postpone the interview if the client is confused.

Rationale 5: I gave her some ibuprofen about 1 hour ago. Ibuprofen will not impact the clients ability to answer questions adequately, so the interview does not need to be postponed.

Global Rationale: The nurse should postpone the interview if the client is in pain. The interview should be postponed if the client received opioid pain medications because it may alter the ability for the client to adequately answer the nurses questions. The nurse should postpone the interview if the client was given lorazepam because it can sedate the client. The nurse should postpone the interview if the client is confused. Ibuprofen will not impact the clients ability to answer questions adequately, so the interview does not need to be postponed.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.6: Discuss the phases of the client interview.

Question 16

Type: MCSA

The nurse says to the client, Before the healthcare provider comes in to see you, we 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. The nurse is participating in which phase of the health assessment interview?

1. Preinteraction

2. The initial interview

3. The focused interview

4. Closure of the interview

Correct Answer: 2

Rationale 1: Preinteraction is when the nurse prepares to meet the client and reviews any available background information.

Rationale 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.

Rationale 3: The focused interview occurs during the physical assessment, while providing treatment, and while providing care to the client.

Rationale 4: Closure of the interview techniques can be used at the end of the initial interview or the focused interview.

Global Rationale: This nurse is conducting the initial interview with this client. The health assessment interview has three phases. Preinteraction is when the nurse prepares to meet the client and reviews any available background information. 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. The focused interview occurs during the physical assessment, while providing treatment, and while providing care to the client. Closure of the interview techniques can be used at the end of the initial interview or the focused interview.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.6: Discuss the phases of the client interview

Question 17

Type: MCSA

During the preinteraction stage, the nurse is preparing for the initial interview. Which of the following settings is the least appropriate setting for the initial interview?

1. The client has been admitted to the hospital with pneumonia. The nurse is preparing to interview the client in the clients private hospital room.

2. The client lives at home. The nurse is preparing to interview the client in the clients living room.

3. The client lives at home. The nurse is preparing to interview the client at a small coffee shop not far from the clients home.

4. The client lives at home. The nurse is preparing to interview the client in the clients backyard.

Correct Answer: 3

Rationale 1: It is appropriate to interview the client in the clients private hospital room.

Rationale 2: When the client lives at home, it is appropriate to interview the client in his living room.

Rationale 3: There should not be other people present during the interview because it may hamper the clients ability to share an adequate amount of information with the nurse.

Rationale 4: It is appropriate to interview the client in his own backyard.

Global Rationale: There should not be other people present during the interview because it may hamper the clients ability to share an adequate amount of information with the nurse. A nearby coffee shop lacks privacy. It is appropriate to interview the client in the clients private hospital room. When the client lives at home, it is appropriate to interview the client in his living room. It is appropriate to interview the client in his own backyard.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.6: Discuss the phases of the client interview.

Question 18

Type: MCSA

The nurse is gathering information regarding the clients psychosocial history. Which of the following questions would be included in this assessment?

1. How did your father die?

2. Have you had any major surgeries?

3. Have you noticed any change in your vision?

4. How long have you worked for your current employer?

Correct Answer: 4

Rationale 1: The nurse should gather information about the reasons for the fathers death when creating the clients genogram and documenting the clients family history.

Rationale 2: Surgical history is a part of medical history.

Rationale 3: Information about vision changes would be included in the review of body systems.

Rationale 4: Elements of the psychosocial history within the health history include gathering information about the clients occupational history, education, financial background, roles and relationships, family, social structure/emotional concerns, and self-concept.

Global Rationale: Elements of the psychosocial history within the health history include gathering information about the clients occupational history, education, financial background, roles and relationships, family, social structure/emotional concerns, and self-concept. The nurse should gather information about the reasons for the fathers death when creating the clients genogram and documenting the clients family history. Surgical history is a part of medical history. Assessment of vision would be included in the Review of Body Systems.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.7: Describe the components of the nursing health history.

Question 19

Type: MCSA

The nurse is obtaining information about a clients past medical history. Which of the following sources would provide the nurse with this data?

1. Medication list

2. Immunization records

3. Average amount of hours of sleep each night

4. Marital status

Correct Answer: 2

Rationale 1: The clients medication list is related to current history. The description of the clients health patterns depicts a lifestyle thread that allows the nurse to see sets of related traits, habits, or acts that affect the clients health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined.

Rationale 2: 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.

Rationale 3: The clients sleep pattern is related to current health history. The description of the clients health patterns depicts a lifestyle thread that allows the nurse to see sets of related traits, habits, or acts that affect the clients health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined.

Rationale 4: The clients marital status is related to current history. The description of the clients health patterns depicts a lifestyle thread that allows the nurse to see sets of related traits, habits, or acts that affect the clients health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined.

Global Rationale: 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. The medication list, sleep pattern, and marital status are related to current history. The description of the clients health patterns depicts a lifestyle thread that allows the nurse to see sets of related traits, habits, or acts that affect the clients health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.7: Describe the components of the nursing health history.

Question 20

Type: MCSA

The nurse is completing a focused interview. Which of the following pieces of information would the nurse include during this interaction?

1. Identify new nursing diagnoses after clarifying previously obtained data.

2. Review information collected during clients previous health screening activities.

3. Obtain biographic data about the client.

4. Review data from previous medical records.

Correct Answer: 1

Rationale 1: The purpose of the focused interview 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.

Rationale 2: Reviewing information collected during the clients previous health screening activities can be performed during the preinteraction stage.

Rationale 3: Obtaining the clients biographical information is included in the preinteraction stage.

Rationale 4: Gathering data from previous medical records is included in the preinteraction stage.

Global Rationale: The purpose of the focused interview 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. Gathering data from previous medical records and biographic data about the client should be performed during the preinteraction stage.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.7: Describe the components of the nursing health history.

Question 21

Type: MCMA

The nurse is gathering client data from secondary sources. Which of the following sources would the nurse utilize to collect this data?

Standard Text: Select all that apply.

1. The clients past medical records

2. The client

3. The history and physical

4. The clients physical therapist

5. The clients spouse

Correct Answer: 1,3,4,5

Rationale 1: The clients past medical records. The clients past medical records is a secondary source of information.

Rationale 2: The client. The client is considered the primary source of information.

Rationale 3: The history and physical. The history and physical is a secondary source of information.

Rationale 4: The clients physical therapist. The clients physical therapist is a secondary source of information.

Rationale 5: The clients spouse. The clients spouse is a secondary source of information.

Global Rationale: Secondary sources are used to augment and validate previously obtained data. The following are examples of secondary sources: medical records, the clients history and physical, a physical therapist who has worked with the client, other healthcare personnel who have cared for the client, and the clients spouse. The client is considered the primary source of information.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.7: Describe the components of the nursing health history.

Question 22

Type: SEQ

The nurse is documenting the following information that has been collected during the health history. Rank the following information in the order that it should be documented.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Diagnosed with renal insufficiency in 1997.

Choice 2. Malignant melanoma (stage I) removed from one site in 1992.

Choice 3. Coronary artery bypass graft in July 2005.

Choice 4. Diagnosed with hypertension in 2000.

Correct Answer: 3,4,1,2

Rationale 1: The third item is the clients diagnosis of renal insufficiency in 1997.

Rationale 2: The fourth item is the clients malignant melanoma that was removed from one site in 1992.

Rationale 3: The first thing that should be documented is the coronary artery bypass graft in July 2005.

Rationale 4: The second item is that the client was diagnosed with hypertension in 2000.

Global Rationale: When recording data, the information should be written in descending order from present to past. The first thing that should be documented is the coronary artery bypass graft in July 2005. The second item is that the client was diagnosed with hypertension in 2000. The third item is the clients diagnosis of renal insufficiency in 1997. The fourth item is the clients malignant melanoma that was removed from one site in 1992.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.8: Obtain a health history.

Question 23

Type: MCSA

The nurse is interviewing an older African American client and determines that a teaching plan should be implemented. Based on the clients race, which statement by the client may prompt the nurse to plan develop a teaching plan?

1. My hands and feet are always cold.

2. I do not take calcium replacements.

3. My blood pressure is high most of the time.

4. Im worried that my bones may be weak.

Correct Answer: 3

Rationale 1: Caucasians have a greater risk for peripheral arterial disease than African Americans. The client with cold hands and feet may have peripheral arterial disease.

Rationale 2: Osteoporosis risk is greater for Asians and Caucasians than for African Americans. People with a high risk for developing osteoporosis should take calcium supplements.

Rationale 3: African Americans have a higher incidence of hypertension and hypertension-related kidney failure than Caucasians.

Rationale 4: African Americans typically have higher bone densities than Caucasians and Asians and are less likely to experience problems to due to osteoporosis.

Global Rationale: African Americans have a higher incidence of hypertension and hypertension-related kidney failure than Caucasians. Caucasians have a greater risk for peripheral arterial disease than African Americans. The client with cold hands and feet may have peripheral arterial disease. Osteoporosis risk is greater for Asians and Caucasians than for African Americans. African Americans typically have higher bone densities than Caucasians and Asians.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.8: Obtain a health history.

Question 24

Type: MCSA

During the course of a health history the nurse would like to review a clients medications. Which of the following questions is most important to ask when gathering the medication history?

1. Can you tell me how much the co-pay is for your medications?

2. Do you carry health insurance?

3. Can you tell me about any over-the-counter or prescription medications that you take?

4. Where do you store your medications in your home?

Correct Answer: 3

Rationale 1: When gathering the medication history, the nurse does not necessarily need to ask about the clients co-pay.

Rationale 2: When gathering the medication history, the nurse does not necessarily need to ask whether the client carries health insurance or not.

Rationale 3: The nurse should gather information about medications that the client is currently using. The nurse should request information about all prescribed and over-the-counter medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins, dietary supplements, or other substances should also be listed.

Rationale 4: The nurse does not necessarily need to ask where the client stores the medications within the home.

Global Rationale: The nurse should gather information about medications that the client is currently using. The nurse should request information about all prescribed and over-the-counter medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins, dietary supplements, or other substances should also be listed. The medication history does not include the clients co-pay amount, if the client has a prescription benefit plan or health insurance, or where in the home the medications are stored.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.8: Obtain a health history.

Question 25

Type: MCSA

A client has been brought to the emergency room by a family member. The client is speaking incoherently. To obtain information about the clients current health status, what should the nurse do?

1. Call the clients healthcare provider.

2. Call the Medical Records department to obtain other records for the client.

3. Discuss the situation with the family member who brought the client to the hospital.

4. Conduct a thorough physical assessment and document the health history as unable to obtain.

Correct Answer: 3

Rationale 1: Speaking with the clients healthcare provider may be helpful when attempting to gather information about the clients medical history. However, the family member may be able to provide more information regarding the clients current health status.

Rationale 2: Contacting the Medical Records department to ascertain this clients old records will be helpful when gathering information about the clients health history.

Rationale 3: 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 a family member. The nurse should talk with the family members.

Rationale 4: The nurse should be able to gather information about the clients current health status from the family member who is accompanying the client. The nurse does not need to document that this information is unavailable.

Global Rationale: 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 a family member. The nurse should talk with the family members. Phoning the healthcare provider or calling Medical Records for other admission information might be appropriate at a later time. The nurse should not document the health history as unable to obtain since family members are available to provide this information.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.8: Obtain a health history.

Question 26

Type: SEQ

The nurse is interviewing a client who has been admitted to the hospital with severe abdominal pain. The nurse is assessing the clients pain using the acronym OLDCART & ICE. Rank the following the statements by the nurse in order of the way they are normally assessed.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. How long have you had this pain?

Choice 2. Would you please point to the location of your pain?

Choice 3. How would you describe your pain? Is it sharp, dull, stabbing?

Choice 4. Can you tell me when your pain first began?

Correct Answer: 3,2,4,1

Rationale 1: The third step is to determine the duration of the clients pain.

Rationale 2: The second step is to identify the location of the clients pain.

Rationale 3: The nurse would then assess the characteristics of the clients pain.

Rationale 4: Using OLDCART & ICE, the nurse would first assess onset of the clients pain.

Global Rationale: Using OLDCART & ICE, the nurse would first assess onset of the clients pain. The second step is to identify the location of the clients pain. The third step is to determine the duration of the clients pain. The nurse would then assess the characteristics of the clients pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.8: Obtain a health history.

Question 27

Type: HOTSPOT

The nurse is creating a family genogram with the clients family history information. Draw an arrow indicating that there are two individuals whom the client is unable to provide any information about for the nurse. [Please insert the genogram from the chapter 10 spec sheet, figure 10-7, only include the bottom portion, do not include any directions regarding how to read or make a genogram.]

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The nurse uses a diamond shape and places the number 2 within the diamond to indicate that there are two of her fathers siblings that she is unable to provide information about for the nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.9: Develop a genogram.

Question 28

Type: MCMA

The nurse is developing a genogram. Which of the following pieces of information can be used to help identify the widowed female?

Standard Text: Select all that apply.

1. A square is used to denote the female.

2. A circle is used to denote the male.

3. A horizontal line connects the circle and the square in the middle.

4. A line above the circle and square that is linked on the top of each shape.

5. The square has a diagonal line through the square from bottom left to upper right corner.

Correct Answer: 3,5

Rationale 1: A square is used to denote the female. A square is used to denote a male.

Rationale 2: A circle is used to denote the male. A circle is used to denote a female.

Rationale 3: A horizontal line connects the circle and the square in the middle. When a horizontal line links the circle and the square in the middle, this indicates that the male and female are married.

Rationale 4: A line above the circle and square that is linked on the top of each shape. A line above the circle and square that is linked on the top of each shape indicates the male and female are siblings.

Rationale 5: The square has a diagonal line through the square from bottom left to upper right corner. A diagonal line through the square indicates the male has died.

Global Rationale: When a horizontal line connects the circle and the square in the middle, this indicates that the male and female are married. A diagonal line through a square or circle indicates that the person has died. A diagonal line through the square indicates the male has died. A square is used to denote a male. A circle is used to denote a female. A line above the circle and square that is linked on the top of each shape indicates the male and female are siblings.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.9: Develop a genogram.

Question 29

Type: MCSA

The nurse is obtaining a family health history when the client reports that a grandparent had type 1 diabetes. Where should the nurse document this information?

1. Family genogram

2. Health practices

3. Past medical history

4. Present health/illness

Correct Answer: 1

Rationale 1: 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 familys health history.

Rationale 2: Health practices and beliefs about health and illness are important for the nurse to ascertain and are included in a general cultural assessment.

Rationale 3: Past medical history includes any major illness, injuries, hospitalizations, allergies, immunizations, and childhood diseases.

Rationale 4: Present health/illness includes information about all of the clients current health-related issues, concerns, and problems as well as the reason for seeking care.

Global Rationale: 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 familys health history. Health practices and beliefs about health and illness are important for the nurse to ascertain and are included in a general cultural assessment. Past medical history includes any major illness, injuries, hospitalizations, allergies, immunizations, and childhood diseases. Present health/illness includes information about all of the clients current health-related issues, concerns, and problems as well as the reason for seeking care.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10.9: Develop a genogram.

Question 30

Type: HOTSPOT

The nurse has created a genogram for the client using the clients family history information. Draw an arrow pointing to the individual who is still alive, a male, and a widower. [Please insert the genogram from the chapter 10 spec sheet, figure 10-7, only include the bottom portion, do not include any directions regarding how to read or make a genogram.]

Screen Shot 2015-09-24 at 11.53.08 AM

Rationale : A square is used to denote a male. A circle is used to denote a female.
Diagonal lines through the shape indicate that the individual has died. Married individuals are linked by a single horizontal line.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10.9: Develop a genogram.

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