Health Assessment

3

Which gesture enables the nurse to communicate effectively with a patient? 1 Slouching in the chair 2 Touching the patient frequently 3 Sitting in close proximity to the patient 4 Asking the patient questions clearly with a loud voice

2

A patient is scheduled for a blood test. The patient asks the nurse for a cup of juice. The nurse tells the patient, "You need to avoid eating or drinking solids or liquids for 12 hours before blood tests because the food may alter the blood test results." Which type of verbal response does the nurse's statement indicate? 1 Empathy 2 Explanation 3 Clarification 4 Confrontation

4

A patient who had been in an accident is admitted to the hospital. The nurse, while assessing, asks whether the patient has pain in the shoulder area. The patient says that there is no pain, but grimaces when the nurse palpates the shoulder. Which verbal response should the nurse use in this situation? 1 Empathy 2 Reflection 3 Explanation 4 Confrontation

4

A pregnant patient tells the nurse, "I haven't felt any fetal movements yet, and I think I may have miscarried." Which response, if made by the nurse would be inappropriate? 1 "Can I get something for you?" 2 "It must be hard to wait for the doctor." 3 "Would you like to talk about anything?" 4 "I am sure that you and your baby are fine."

4

During the interview, a patient tells the nurse, "I don't get enough sleep at night, at the most three hours. It makes me tired all the time." Which is the best response by the nurse? 1 "No wonder you are tired! You need to get more sleep." 2 "That is unusual. You must be exaggerating a bit." 3 "That's terrible! I have a lot of trouble sleeping myself." 4 "Did you say that you sleep only three hours every night?"

4 Amphetamine is a central nervous system stimulant drug that causes excessive agitation and paranoid behavior. The adolescent is agitated and unwilling to answer any questions asked by the nurse. This indicates mistrust, which is the main characteristic of paranoid behavior. Heroin and morphine are central nervous system depressants; they slow the brain activity and decrease the intellectual performance. Ketamine is a hallucinogen that causes bizarre and violent behavior

While entering the room of an adolescent who is a drug addict, the nurse observes that the adolescent becomes agitated and says, "I'm not going to answer any of your questions." This behavior could indicate abuse of which drug? 1 Heroin 2 Morphine 3 Ketamine 4 Amphetamine

1, 3, 4, 5

What are the advantages of using trained interpreters in patient interviews? Select all that apply. 1 Improved primary care 2 Increased admission rates 3 Increased patient satisfaction 4 Maintain patient confidentiality 5 Improved overall health outcomes

1, 2, 4

What are the characteristics of the Test of Functional Health Literacy Assessment (TOFHLA) tool? Select all that apply. 1 Uses actual client instructions 2 Takes approximately 22 minutes 3 Includes various terms of medicine 4 Helps measure comprehension and numeracy 5 Uses a nutrition label that the patient should read and interpret

1, 3, 4

What are the internal factors of communication? Select all that apply. 1 Liking others 2 Ensuring privacy 3 Listening ability 4 Providing empathy 5 Refusing interruptions

1

What distance between two individuals indicates the intimate zone? 1. 1 ft 2. 3 ft 3. 5 ft 4. 13 ft

2

What distance should the nurse maintain from a patient while conducting an interview? 1 Intimate 2 Social distance 3 Public distance 4 Personal distance

3

What is a positive nonverbal behavior of an interviewer? 1 Bland expression 2 High-pitched tone 3 Equal-status seating 4 Slouching in the chair

2

What is an advantage of using a patient explanatory model during a clinical interview? 1 It helps the nurse comprehend the patient's chief complaint. 2 It helps convey the meaning of medical terms used. 3 It helps the nurse find a common connection with the patient. 4 It helps promote trust between a nurse and patient.

Imaginative Play Piaget proposed different stages of cognitive development. Different stages have different characteristic features. Children in the preoperational stage start developing symbolic thinking. Thus, these children engage in imaginative play. Children in the concrete operational stage understand the concepts of classification and conservation. Thus, logical thinking is a characteristic feature of concrete operations stage. Children in the formal operations stage develop abstract thinking and tend to have futuristic ideas. These children have a broad and theoretical perspective.

What is the characteristic feature of the preoperational stage of Piaget's theory?

3

What is the primary purpose of interviewing a patient? 1 To allow the patient to become acquainted with the nurse 2 To teach preventive health care methods to the patient 3 To get the patient's health history and current health status 4 To correlate the patient's complaints with objective signs

2

Which age of a child will be included in the preoperational stage of cognitive development according to Piaget? 1 1 year old 2 3 years old 3 10 years old 4 12 years old

1, 3, 4

Which characteristic behaviors of the nurse suggest an interest in what a patient is saying during an interview? Select all that apply. 1 Nodding 2 Sitting quietly 3 Leaning forward 4 Maintaining eye contact 5 Asking questions on other topics

3

Which characteristic of linguistic development is likely to be observed in a 2-year-old child according to Piaget's stages of cognitive development? 1 Use of pronouns 2 Use of passive tense 3 Use of short sentences 4 Use of complex grammar

1

Which child is in the stage of presymbolic language development? 1 2-year-old child 2 3-year-old child 3 4-year-old child 4 5-year-old child

1, 3, 4

Which criteria should the nurse consider when choosing an interpreter to assist in interviewing an immigrant patient? Select all that apply. 1 The interpreter should be mature. 2 The interpreter should be economically well-off. 3 The interpreter should not belong to the patient's rival group. 4 The interpreter should be well aware of the patient's language. 5 The interpreter should belong to the opposite gender of the patient.

4

Which factor can adversely affect the outcome of the patient interview? 1 The patient's reason for the visit 2 The chronological age of the patient 3 Knowing the history of the patient 4 The nurse-patient compatibility

3

Which is the most effective communication technique during a clinical interview? 1 Providing support 2 Avoiding eye contact 3 Active listening 4 Giving advice

2, 3, 4

Which measures should the nurse take to communicate effectively with a patient? Select all that apply. 1 Provide bright lighting in the communication room. 2 Avoid standing while communicating with the patient. 3 Avoid facing a patient across a desk during communication. 4 Keep 4 to 5 feet of distance with the patient during communication. 5 Avoid placing the chairs at a 90-degree angle during communication.

3, 4, 5

Which nonverbal behaviors of the nurse will have a positive impact on a patient during an interview? Select all that apply. 1 The nurse has a slow rate of speech during the interview. 2 The nurse focuses on writing notes during the interview. 3 The nurse leans slightly toward the patient during the interview. 4 The nurse provides empathy to the patient using appropriate touch. 5 The nurse maintains eye contact with the patient during the interview.

2

Which question will be most helpful to the nurse in obtaining information from the patient regarding an illness? 1 "What do the symptoms feel like?" 2 "What other changes did you notice?" 3 "Is there anything that makes it worse?" 4 "When did you first notice this issue?"

3

Which type of question encourages a patient to focus on specific information? 1 Open-ended 2 Narrative 3 Direct 4 Clarifying

1

While conducting an interview, the nurse finds that the patient is aggressive and giving flirtatious compliments to the nurse. The nurse feels uncomfortable and tells the patient, "I feel uncomfortable when you talk to me that way." The nurse finds that the patient's behavior continues in the same manner. What action should the nurse take next? 1 Discontinue the patient's interview. 2 Seclude the patient in a separate room. 3 Obtain additional support from other staff member. 4 Ask the patient's family member to sit beside the patient

1, 3, 4

While interviewing a patient who is a drug addict, the nurse finds that the patient has poor motor coordination, impaired judgment, and poor memory. Given these symptoms, which drugs may the patient be abusing? Select all that apply. 1 Heroin 2 Cocaine 3 Morphine 4 Methadone 5 Amphetamine

3

While interviewing a patient, the nurse observes that the patient is taking frequent and long pauses while speaking. The patient's speech is slow, monotonous, and weak. What does the nurse infer from this observation? 1 The patient may be shy. 2 The patient may be anxious. 3 The patient may be depressed. 4 The patient may be hearing impaired.

1, 2, 3

While interviewing an adolescent, the nurse finds that the adolescent gives responses in monosyllables. Which interventions should the nurse use to make the communication more successful? Select all that apply. 1 The nurse asks short and simple questions. 2 The nurse avoids using reflection type of verbal responses. 3 The nurse asks questions about the hobbies of the patient. 4 The nurse asks the parent to stay in the interview room. 5 The nurse permits frequent silent periods during the interview.

2, 4, 5

A nurse is preparing for a patient interview. What tasks does the nurse complete before the interview begins? Select all that apply. 1 Ensure direct, bright light in the room. 2 Turn off the television and radio in the room. 3 Ask the patient to change into a hospital gown. 4 Ask the accompanying family member to step out. 5 Request other staff not to interrupt the discussion.

2

The charge nurse is observing a new nurse who is interviewing a psychotic patient with a history of violent behavior. The charge nurse would be most concerned if the nurse takes which action? 1 The nurse talks to the patient in a soft voice. 2 The nurse closes the door of the interview room. 3 The nurse stands between the door and the patient. 4 The nurse faces the patient at all times.

1

The nurse is assessing a patient who has an unsteady gait and lacks coordination. The nurse finds that the patient abuses alcohol. What should be the first question asked by the nurse to the patient during the interview? 1 "When did you take your last drink?" 2 "Did anyone ask you to quit drinking?" 3 "With whom did you have your last drink?" 4 "Have you injured anyone because of your drinking?"

1, 2, 5

The nurse is assessing an immigrant patient with the help of an interpreter. What actions should the nurse take to conduct an effective interview? Select all that apply. 1 Ensure that the interpreter is not related to the patient. 2 Instruct the interpreter to explain medical jargon to the patient. 3 Ask the interpreter to complete the interview in a limited time period. 4 Have the interpreter avoid discussing the purpose of the investigation. 5 Request the interpreter to provide a verbatim account of the conversation.

2

The nurse is assessing the patient's posture. What distance should the nurse maintain from the patient during this assessment? 1 1 foot 2 2 feet 3 5 feet 4 7 feet

3

The nurse is caring for an elderly patient who is anxious and lonely. During the interaction, the patient tells the nurse, "My family doesn't care for me, and nobody wants to visit me." Which response would indicate that the nurse is reassuring the patient? 1 "What would you like to eat for lunch?" 2 "Which family member loves you most?" 3 "I will be here to care for you throughout the day." 4 "Tell me something about your family members."

1, 2, 3

The nurse is conducting an interview of a patient who is under the influence of alcohol. Which interventions should the nurse implement to conduct the interview successfully? Select all that apply. 1 Avoid scolding the patient. 2 Maintain eye contact with the patient. 3 Provide sufficient lighting in the room. 4 Ask open-ended questions to the patient. 5 Ask the patient's family member to sit beside the patient.

2

The nurse is conducting an interview of an immigrant adolescent who does not understand English. The nurse asks an ad hoc interpreter to interpret the information. What outcome might occur when using such an interpreter? 1 Increased stress in the patient 2 Violation of patient confidentiality 3 Improved overall health outcomes 4 Increased satisfaction of the patient

1, 4, 5 Linguistic problems are a barrier to effective communication. While conducting an interview of an immigrant patient, the nurse should greet the patient using the patient's complete name to show respect. The nurse should ask if any of the patient's family members can communicate in English and can serve as an interpreter for effective communication. However, having a family member as an interpreter is not ideal and may result in a breach of patient confidentiality. The nurse should use any words that the nurse might know in the patient's language because it indicates that the nurse is aware of the patient's language and respects the patient's culture. The nurse should not speak loudly while communicating with the patient because the patient may feel that the nurse is authoritarian and disrespectful. The nurse should use simple words and avoid using contractions to limit any confusion during interaction.

The nurse is conducting an interview of an immigrant patient. The language interpreter is not available. Which measures should the nurse take to conduct the interview effectively? Select all that apply. 1 Greet the patient using his or her complete name. 2 Speak loudly while communicating with the patient. 3 Use contractions while communicating with the patient. 4 Use any words that the nurse might know in the patient's language. 5 Ask whether a person in the patient's family could serve as an interpreter.

3

The nurse is interviewing a lesbian. Which strategy should the nurse implement for effective communication? 1 Follow a special question format for the patient. 2 Use the opposite-gender interpreter for the patient. 3 Use the term "partner" during interaction instead of "husband" or "wife." 4 Ask the patient's partner to sit beside the patient during the interview.

2, 3, 5

The nurse is interviewing a patient with psychosis. Which behaviors would indicate to the nurse that the patient may exhibit violent behavior? Select all that apply. 1 The patient starts crying. 2 The patient clenches the fists. 3 The patient moves back and forth. 4 The patient is extremely anxious. 5 The patient stares blankly at the nurse.

1

The nurse is interviewing a pregnant patient. The patient tells the nurse, "I cannot think of being on bed rest now because I have kids at home and I'm worried about them." Which statement by the nurse indicates that the nurse has given a reflection type of verbal response? 1 "You feel worried and anxious about your children." 2 "You must be finding it hard to stay away from the children." 3 "You feel worried about your children because you love them a lot." 4 "You have to control your emotions because it may affect your health."

3

The nurse is obtaining subjective data from a patient. Which is a closed-ended question that the nurse includes in this interview? 1 "Tell me a little about yourself." 2 "How are you feeling today?" 3 "Do you smoke cigarettes often?" 4 "What brings you here today?"

3 The nurse should follow different strategies when interacting with patients of different age groups. The nurse should begin the interview with the parent, because when the child sees that the parent is comfortable with the nurse, the child would feel relaxed and start to cooperate during the interview. The nurse can give toys to the child while interacting with the parent. The nurse should not maintain eye contact with the child, because this may frighten the child. The nurse should greet the child and parent by name so that child and the parent feel comfortable.

The nurse prepares to interview a 6-year-old child. The nurse greets the child and the parent by name and communicates with the child first and then with the parent. The nurse does not maintain eye contact with the child and gives toys to the child while interacting with the parent. Which action by the nurse is inappropriate? 1 Giving toys to the child 2 Avoiding eye contact with the child 3 Communicating with the child first 4 Greeting the child and parent by name

2

The nurse teaches a student nurse about developing contracts with patients. Which statement, if made by the student nurse, indicates effective learning? 1 "A verbal contract is the most useful tool for behavior modification." 2 "A contract is an agreement that sets the expectations of each party." 3 "A contract is developed after the nurse has determined the problem." 4 "A contract is a verbal agreement about the scheduled plan of care."

4

The student nurse interviews an adolescent patient. After the interview, the patient reports to the nurse that the student nurse seemed to be aloof and not concerned. Which behavior of the student nurse may have led the patient to have this opinion? 1 The student nurse stands during the interview. 2 The student nurse calls the patient by the first name. 3 The student nurse asks open-ended questions to the patient. 4 The student nurse maintains a distance of 8 feet from the patient.