Physical Examination and Health Assessment- Applying (Application)

When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior? a. Lean forward slightly and making eye contact ask "Is there anything else?" b. Smile at him and say, "Don't worry about all of this. I'm sure we can get to the bottom of your symptoms." c. Lean back in the chair and ask, "You are looking at me kind of funny; there isn't anything wrong, is there?" d. Stand up and say, "I can see that this interview is uncomfortable for you. We can continue it another time."

ANS: A Typically patients will answer questions with short answers and then pause and look to the health care provider for direction on whether to continue. In this case, the health care provider should lean forward slightly, make eye contact, and look interested and if the patient does not continue, then ask them to tell you more or ask if there anything else. The other responses are not conducive to ideal communication. Leaning back in the chair or standing up indicates disinterest or closure and making statements such as "Don't worry about all of this. I'm sure we can get to the bottom of your symptoms;" "You are looking at me kind of funny; there isn't anything wrong, is there?"; or "I can see that this interview is uncomfortable for you. We can continue it another time" dismiss the patient's feelings or are confrontational and are not conducive to ideal communication. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is caring for several patients on a pediatric unit. Which patient should the nurse be most concerned about possible abuse? a. A 4-month-old with bruises on the arms b. A 2-year-old with bruises on the knees c. An 8-year-old with a broken right arm d. A 15-year-old football player with a broken leg

ANS: A Accidental bruising in healthy, active children is common, but infants who are not yet walking with support (e.g. cruising around furniture) typically should not have bruises. Bruising in infants who are not yet cruising, usually infants younger than 9 months, should alert you to possible abusive mechanisms to the injury or an underlying medical illness. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. Which assessment finding should the nurse expect? a. Hypertension b. Ventricular fibrillation c. Bradycardia d. Mitral valve prolapse

ANS: A Alcohol has many effects on the cardiovascular (CV) system. Studies show that consuming more than 1 or 2 drinks of alcohol a day is associated with hypertension. Ventricular fibrillation, bradycardia, and mitral valve prolapse are not associated with chronic heavy use of alcohol. Although alcohol has many effects on the cardiovascular (CV) system, it is not associated with ventricular fibrillation, bradycardia, or mitral valve prolapse. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

An adult male is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and to take off his undergarments. d. Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.

ANS: A Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person's vital signs, will gradually accustom the person to the examination. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? a. "Can you point to where it hurts?" b. "What have you had to eat in the last 24 hours?" c. "Have you ever had any surgeries on your abdomen?" d. "We'll talk more about that later in the interview."

ANS: A As a person talks, the nurse should not come to any conclusions but should collect all data first of a symptom. A final summary of any symptom the person has should include the specific location, so having the patient point to where the pain is located is appropriate. There are eight critical characteristics to be included in the summary of any symptom: "Location, Character or Quality, Quantity or Severity, Timing, Setting, Aggravating or Relieving Factors, Associated Factors, and Patient's Perception. Options B, C, and D do not collect the necessary data to make a summary of the symptom. A final summary of any symptom the person has should include eight critical characteristics: "Location, Character or Quality, Quantity or Severity, Timing, Setting, Aggravating or Relieving Factors, Associated Factors, and Patient's Perception." DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This is an example of which speech pattern? a. Echolalia b. Clanging c. Word salad d. Perseveration

ANS: A Echolalia occurs when a person imitates or repeats another's words or phrases, often with a mumbling, mocking, or a mechanical tone. Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. Word salad is an incoherent mixture of words, phrases, and sentences. Perseveration is the persistent repeating of verbal or motor response, even with varied stimuli. The statements in this question describe echolalia. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene? a. Percussing once over each area b. Striking with the fingertip, not the finger pad c. Using the wrist to make the strikes, not the arm d. Quickly lifting the striking finger after each stroke

ANS: A For percussion, the nurse should percuss 2 times over each location (not once). The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

During change of shift report, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. b. Woman hears the doorbell ring and goes to answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

ANS: A Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

When caring for children with a different cultural perspective, what should the nurse recognize may pose a challenge? a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents' perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their children's spiritual needs.

ANS: A Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. "Do you take medicine?" b. "Are you in any discomfort?" c. "Do you have nausea and vomiting?" d. "You have been following your doctor's orders, haven't you?"

ANS: A In a situation during which a language barrier exists and no interpreter is available, simple words should be used, such as "Do you take medicine" or the word pain rather than discomfort. The use of medical jargon, contractions, and pronouns should be avoided. Nouns should be repeatedly used, and one topic at a time should be discussed. Simple words like pain should be used rather than words like discomfort, nausea, and vomiting. The use of contractions such as "haven't" as well as medical jargon and pronouns should be avoided. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

During a mental status examination, the nurse wants to assess a patient's affect. Which question the nurse should ask? a. "How do you feel today?" b. "Would you please repeat the following words?" c. "Have these medications had any effect on your pain?" d. "Has this pain affected your ability to get dressed by yourself?"

ANS: A Mood and affect should be judged by observing body language and facial expression and by directly asking, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should appropriately change with the topics. Options B, C, and D do not assess affect. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.

ANS: A Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person's behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed? a. Rotating the lens selector dial to bring the object into focus b. Using the large full circle of light when assessing pupils that are not dilated c. Rotating the lens selector dial to the black numbers to compensate for astigmatism d. Using the grid on the lens aperture dial to visualize the external structures of the eye

ANS: A The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospital's safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary.

ANS: A The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from "evil spirits." When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet's meaning to the patient. Asking the patient to lock the item with other valuables in the hospital's safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient's cultural health practices. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

As the nurse enters a patient's room, the nurse finds the patient crying. The patient states that she has just found out that the lump in her breast is cancer and says, "I'm so afraid of, um, you know." Which would be the most therapeutic response by the nurse when said in a gentle manner? a. "You're afraid you might lose your breast?" b. "No, I'm not sure what you are talking about." c. "I'll wait here until you get yourself under control, and then we can talk." d. "I can see that you are very upset. Perhaps we should discuss this later."

ANS: A This statement demonstrates reflection. Reflection echoes the patient's words, repeating part of what the person has just said, and it also can help express the feelings behind a person's words. Stating "No, I'm not sure what you are talking about" is not the most therapeutic response as it does not acknowledge the patient's feelings. Stating "I'll wait here until you get yourself under control, and then we can talk" or "I can see that you are very upset. Perhaps we should discuss this later" are not therapeutic as they are not addressing the patient's feelings and concerns at the time. DIF: Cognitive Level: Applying (Application)

An Asian-American woman is experiencing diarrhea, which is believed to be "cold" or "yin." What should the nurse recognize that the woman may likely to try to treat it? a. Foods that are "hot" or "yang" b. Readings and Eastern medicine meditations c. High doses of medicines believed to be "cold" d. No treatment because diarrhea is an expected part of life

ANS: A Yin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. The other explanations do not reflect the yin/yang theory. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop "cold turkey." He asks the nurse, "What symptoms can I expect if I do this?" Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? (Select all that apply.) a. Headaches b. Hunger c. Sleepiness d. Restlessness e. Nervousness f. Sweating

ANS: A, B, D, E Symptoms of nicotine withdrawal include vasodilation, headaches, anger, irritability, frustration, anxiety, nervousness, awakening at night, difficulty concentrating, depression, hunger, impatience, and the desire to smoke. Sleepiness and sweating are not symptoms of nicotine withdrawal. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse assesses an older woman and suspects physical abuse. Which questions are appropriate for screening for abuse? (Select all that apply.) a. "Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?" b. "Are you being abused?" c. "Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?" d. "Have you been upset because someone talked to you in a way that made you feel shamed or threatened?" e. "Has anyone tried to force you to sign papers or to use your money against your will?"

ANS: A, C, D, E Directly asking "Are you being abused?" is not an appropriate screening question for abuse because the woman could easily say "no," and no further information would be obtained. The other questions are among the questions recommended by the Elder Abuse Suspicion Index (EASI) when screening for older adult abuse. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

The nurse is asking questions about a patient's health beliefs. Which questions are appropriate? (Select all that apply.) a. "What is your definition of health?" b. "Does your family have a history of cancer?" c. "How do you describe illness?" d. "What did your mother do to keep you from getting sick?" e. "Have you ever had any surgeries?" f. "How do you keep yourself healthy?"

ANS: A, C, D, F The questions listed are appropriate questions for an assessment of a patient's health beliefs and practices. The questions regarding family history and surgeries are part of the patient's physical history, not the patient's health beliefs. Questions regarding family history and surgeries are not part of a patient's health beliefs, but are part of the patient's physical history. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. Which is the best response by the nurse? a. "I'm so sorry for making you cry!" b. "I can see that you are sad remembering this. It is all right to cry." c. "Why don't I step out for a few minutes until you're feeling better?" d. "I can see that you feel sad about this; why don't we talk about something else?"

ANS: B A beginning examiner may feel uncomfortable when a patient starts crying. When the nurse says something that "makes the person cry," the nurse should not think he or she has hurt the person. The nurse has simply hit on an important topic; therefore, the nurse should allow the person to cry and to express his or her feelings fully. The nurse can offer a tissue and wait until the crying subsides to talk. When the nurse says something that "makes the person cry," the nurse should not think he or she has hurt the person. The nurse has simply hit on an important topic. The nurse should not apologize, leave the person alone, or change the topic, but rather allow the person to cry and express his or her feelings fully. The nurse can offer a tissue and wait until the crying subsides to talk. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

During a mental status assessment, which question by the nurse would best assess a person's judgment? a. "Do you feel that you are being watched, followed, or controlled?" b. "Tell me what you plan to do once you are discharged from the hospital." c. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" d. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

ANS: B A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations, and the capacity for violent or suicidal behavior. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? a. Patient has a history of drug abuse and therefore is not reliable. b. Patient provided consistent information and therefore is reliable. c. Patient smiled throughout interview and therefore is assumed reliable. d. Patient would not answer questions concerning stress and therefore is not reliable.

ANS: B A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A mother and her 13-year-old daughter express their concern r/t the daughter's recent weight gain and her increase in appetite. Which of these statements represents information the nurse should discuss with them? a. Dieting and exercising are necessary at this age. b. Snacks should be high in protein, iron, and calcium. c. Teenagers who have a weight problem should not be allowed to snack. d. A low-calorie diet is important to prevent the accumulation of fat.

ANS: B After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase.

A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to "warm up" and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.

ANS: B Although most of the communication is with the parent, the nurse should not completely ignore the child. Making contact will help ease the toddler later during the physical examination. The nurse should begin by asking about the toys the child is playing with or about a special doll or teddy bear brought from home. "Does your doll have a name?" or "What can your truck do?" Stoop down to meet the child at his or her eye level. Although making contact with the toddler will help ease him/her later during the physical examination, the nurse should begin by asking about the toys the child is playing with or about a special doll or teddy bear brought from home before touching or tickling them. Children are frightened by quick or grandiose gestures. The nurse should not completely ignore the child as making contact will help ease the toddler later during the physical examination. The nurse should not ask the mother to leave during the examination as that will cause anxiety for the toddler. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What should the nurse recommend? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21. d. A recommendation cannot be made until the physician is consulted.

ANS: B Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics (2018) recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. "Why did you come to the United States?" b. "When did you come to the United States and from what country?" c. "What made you leave your native country?" d. "Are you planning to return to your home?"

ANS: B Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions. When a patient is a new immigrant several biographic questions should be added to the health history. Why the person came to the United States, what made him/her leave his/her native country, and when he/she is planning to return are not necessary and do not provide any biographic data. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

During a visit to the clinic, a patient states, "The doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I've tried. I just don't know the best way to do it. What should I do?" What is the most appropriate response by the nurse? a. "I'd quit if I were you. The doctor really knows what he is talking about." b. "Would you like some information about the different ways a person can quit smoking?" c. "Stopping your dependence on cigarettes can be very difficult. I understand how you feel." d. "Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer?"

ANS: B Clarification should be used when the person's word choice is ambiguous or confusing. Clarification is also used to summarize the person's words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track. The other responses give unwanted advice or do not offer a helpful response. Saying "I'd quit if I were you. The doctor really knows what he is talking about", "Stopping your dependence on cigarettes can be very difficult. I understand how you feel", or "Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer?" either provide unwanted advice or do not offer a helpful response. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? a. Record the results of the assessment, and notify the physician on call. b. State, "You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm willing to help you." c. State, "It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter." d. Give the patient information about a local rehabilitation clinic.

ANS: B If an assessment has determined that the patient has at-risk drinking behavior, then the nurse should give a short but clear statement of assistance and concern. Simply giving out a telephone number or referral to agencies may not be enough. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. P-6, B-4, (S)Ab-2 b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant 6 times.

ANS: B Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (miscarriages or abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion. Option A does not use approved medical abbreviations and does not include the number of living children. Options C and D do not include all the pertinent data of the person's obstetric history. Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (miscarriages or abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. "It would help to interview the three of you together." b. "While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?" c. "Please stay during the interview; you can answer for her if she does not know the answer." d. "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?"

ANS: B The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires. Options A, C, and D are inappropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A 16-year-old boy has just been admitted to the hospital for overnight observation after being in an automobile accident. What is the best approach for the nurse to use to communicate with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up.

ANS: B The guidelines for communicating with adolescents are simple. The first consideration is one's attitude, which must be one of respect. Second, communication must be totally honest. An adolescent's intuition is highly tuned and can detect phoniness or the withholding of information. Always tell him or her the truth. The nurse should avoid periods of silence when communicating with adolescents as silence can be seen as threatening to them. The nurse should not tell an adolescent that everything will be confidential as that is not true. Something need to be reported by law or for the adolescent's well-being. While it is helpful to understand the jargon or slang used by adolescents, the nurse should not use that language as they are not part of the adolescent's peer group and won't be accepted as a peer. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

Which adjustment in the physical environment should the nurse make to promote the success of an interview? a. Arrange seating across a desk or table. b. Reduce noise by turning off televisions and radios. c. Reduce the distance between the interviewer and the patient to 2 feet or less. d. Provide dim lighting to make the room cozy and help the patient relax.

ANS: B The nurse should secure a quiet environment, thus, should reduce noise by turning off the television, radio, and other unnecessary equipment, because multiple stimuli are confusing. The interviewer and patient should be approximately 4 to 5 feet apart; the room should be well-lit, enabling the interviewer and patient to see each other clearly. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. The interviewer and patient should be approximately 4 to 5 feet apart. Sitting closer than that to a patient, or encroaching on them, can cause anxiety. The room should be well-lit, enabling the interviewer and patient to see each other clearly. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

A woman is discussing the problems she is having with her 2-year-old son. She says, "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." Which is the best response by the nurse to gain a better understanding of the problem? a. "Go on, I'm listening." b. "Fits? Tell me what you mean by this." c. "Yes, it can be upsetting when a child has a fit." d. "Don't be upset when he has a fit; every 2 year old has fits."

ANS: B The nurse should use clarification when the person's word choice is ambiguous or confusing (e.g., "Tell me what you mean by fits."). Clarification is also used to summarize the person's words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track. Telling the woman "Go on, I'm listening"; "Yes, it can be upsetting when a child has a fit"; or "Don't be upset when he has a fit; every 2 year old has fits" does not allow the nurse to clarify what the woman means by the term "fits" which is necessary to gain a better understanding of the problem. The nurse should use clarification when the person's word choice is ambiguous or confusing (e.g., "Tell me what you mean by fits."). Clarification is also used to summarize the person's words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse has used interpretation regarding a patient's statement or actions. What should the nurse do after using this technique? a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurse's conclusion on the basis of the patient's nonverbal response.

ANS: B The nurse's, or interviewer's, interpretation of a patient's statement is based on their inference or conclusion. The nurse risks making the wrong inference. Pausing after an interpretation allows time for the patient to correct it if it is wrong. Even if the inference is correct, interpretation helps prompt further discussion of the topic. Apologizing after interpreting a patient's statement should not be necessary as the nurse should have stated that the interpretation is just his or her own inference from what the patient said and not a conclusion and is open for clarification. Continuing the interview as if nothing has happened or immediately restating the nurse's conclusion based on the patient's nonverbal response does not allow time for the patient to confirm or correct the inference. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. "Do you wear glasses?" b. "Are you able to dress yourself?" c. "Do you have any thyroid problems?" d. "How many times a day do you have a bowel movement?"

ANS: B Whether a person is able to dress himself or herself assesses his/her ability to perform an activity of daily living. A functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that he/she can or cannot do. The other responses do not relate to functional assessment. Asking whether a patient wears glasses, has any thyroid problems, and how many bowel movements he or she has each day are not part of a functional assessment. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thought he had influenza, but she became concerned when his temperature went up to 39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? a. Alcohol b. Heroin c. Cocaine d. Sedative

ANS: B Withdrawal symptoms of opiates, such as heroin, are similar to the clinical picture of influenza and include symptoms such as dilated pupils, lacrimation, runny nose, tachycardia, fever, restlessness, muscle and joint pains, and other symptoms. These symptoms are not consistent with withdrawal form alcohol, cocaine, or sedatives. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? (Select all that apply.) a. Bradycardia b. Coarse tremor of the hands c. Transient hallucinations d. Somnolence e. Sweating

ANS: B, C, E Symptoms of uncomplicated alcohol withdrawal start shortly after the cessation of drinking, peak at the second day, and improve by the fourth or fifth day. Symptoms include coarse tremors of the hands, tongue, and eyelids; anorexia; nausea and vomiting; autonomic hyperactivity (e.g., tachycardia, sweating, elevated blood pressure); and transient hallucinations, among other symptoms (see Table 6-7). Bradycardia and somnolence are not symptoms of alcohol withdrawal. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? a. "Ethnicity is dynamic and ever changing." b. "Ethnicity is the belief in a higher power." c. "Ethnicity pertains to a social group that may possess shared traits such as religion and language." d. "Ethnicity is learned from birth through the processes of language acquisition and socialization."

ANS: C Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinician's experience. d. EBP does not consider the patient's own preferences as important.

ANS: C Physical Examination and Health Assessment 8th Edition 0323510809 EBP is a systematic approach to practice that emphasizes the use of research evidence in combination with the clinician's expertise and clinical knowledge (physical assessment), as well as patient values and preferences, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists.

A visiting nurse is making an initial home visit for a patient who has several chronic medical problems. Which type of database is most appropriate to collect in this setting? a. A follow-up database b. A focused database c. A complete database d. An emergency database

ANS: C A complete database is collected in primary care settings, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. In these settings, the nurse is the first health professional to see the patient and has the primary responsibility for monitoring the person's health care. A follow-up database is performed to follow up, or evaluate changes, on short-term and chronic health problems, but would be collected at appropriate intervals after a complete database was collected at the initial visit. A focused database is conducted for a limited or short-term problem, not for a patient with several chronic problems. An emergency database is an urgent, rapid collection of data often compiled concurrently while lifesaving measures are being performed. MSC: Client Needs: Safe and Effective Care Environment: Management of Care

An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. When admitting this patient, what would a culturally sensitive nurse do? a. Contact the hospital administrator about the best course of action. b. Arrange for a shaman for her, because requesting one herself is not culturally appropriate. c. Further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families.

ANS: C A health care provider should not assume an understanding of a person's culture but should ask about cultural beliefs that may impact the health care provided, such as health practices and religious beliefs. Some people may believe that the cure is incomplete unless the body, mind, and spirit are also healed so may seek help from folk or religious healers in addition to biomedical or scientific health care. Members of the Mexican-American culture often seek care of curandero or priest. The nurse should conduct a cultural assessment of the patient to learn about her cultural beliefs that may impact the health care provided, not contact the hospital administrator. The nurse should not arrange for a folk healer before finding out the patient's beliefs on health care practices and also a Shaman is the typical folk healer for a American Indians. The nurse should not ask the family their preferences, but the patient herself. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is caring for a 17-year-old female patient. In which situation should the nurse screen the patient for intimate partner violence (IPV)? a. When intimate partner violence is suspected b. When a history of abuse in the family is known c. As a routine part of each health care encounter d. As part of the exam for a female with an unexplained injury

ANS: C According to the latest guidelines published by the U.S. Preventive Services Task Force, all women of childbearing age (14 to 46 years) should be screened for IPV. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing the mental status of this patient? a. "Please count backward from 100 by 7." b. "I will name three items and ask you to repeat them in a few minutes." c. "Please point to articles in the room and parts of the body as I name them." d. "What would you do if you found a stamped, addressed envelope on the sidewalk?"

ANS: C Additional tests for people with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing (asking the person to make up and write a sentence). Aphasia is a disorder of language comprehension. To assess the mental status of a patient with aphasia, the nurse should ask questions to assess her comprehension. The other options do not assess a person's comprehension. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is examining a 3-year-old child who was brought to the emergency department after a fall. Which bruise, if found, would be of most concern? a. Bruises on the knee b. Bruises on the elbow c. Bruises on the abdomen d. Bruises on both of the shins

ANS: C Bruising in atypical places, such as the buttocks, hands, feet, and abdomen, is exceedingly rare and should arouse concern. In children younger than 4 years, bruising on the torso, ears, and neck are significantly correlated with abuse in the absence of a compelling history. Children who are walking often have bruises over the bony prominences of the front of their bodies, so bruises on the knees, elbows, and shins are not unusual. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? a. Trying prayer before seeking medical help. b. Believing that illness is a punishment of sin. c. Refusing to accept blood products as part of treatment. d. Stating that a child's birth defect is the result of the parents' sins.

ANS: C Cultural taboos are practices that are to be avoided, such as receiving blood products, eating pork, and consuming caffeine. The other answers do not reflect cultural taboos. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do next? a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope.

ANS: C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. When unable to palpate a pulse, a Doppler device should be used. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is caring for an 8-year-old child who has several bruises of varying colors (some red, some bluish-green, and some brownish-yellow) the size of a hand on the buttocks. What action should the nurse take next? a. Notify the child's caregivers of the findings. b. Document that the bruises appear to be caused by spanking. c. When the child is alone, ask "How did you get these sore areas on your butt?" d. Inform the child "You can tell me who did this to you and we will not allow them to see or hurt you again."

ANS: C If a child is verbal, a history should be obtained away from the caregivers through open-ended questions or spontaneous statements. Keeping the question short and using age-appropriate language and familiar words can help enrich the history taking. Children older than 11 years can generally be expected to provide a history at the level of most adults. The nurse should not confront the caregivers, as they may be the abusers. Documentation of finding should be objective, thorough, and unbiased; thus, the nurse should not document that the bruises appear to be caused by spanking. Children, even if abused by their caregivers, are usually afraid to be separated from their caregivers or get them into trouble, so if the nurse tells the child that they will not allow the person who did this to the child to see the child again, the child is very unlikely to admit it was the caregiver(s). DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore to assess the mental status during the interview? a. "I sleep like a baby." b. "I have no health problems." c. "I never did too good in school." d. "I am not currently taking any medications."

ANS: C In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patient's normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits. A patient stating that he/she sleeps like a baby, has no health problems, or is currently not taking any medications are not r/t the patient's mental status. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. "This has been a difficult year for you." b. "I don't know how anyone could handle that much stress in 1 year!" c. "What did you do to cope with the loss of both your husband and mother?" d. "That is a lot of stress; now let's go on to the next section of your history."

ANS: C Questions about coping and stress management include questions regarding the kinds of stresses in one's life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful. Options A, B, and D do not assess the person's methods to cope or alleviate their stress. When asking questions about coping and stress, the nurse should ask regarding the kinds of stresses in one's life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the assessment? a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should not have declined. d. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge.

ANS: C The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Wash hands and then contact the physician. b. Continue to examine the ulceration and then wash hands. c. Wash hands, put on gloves, and continue with the examination of the ulceration. d. Wash hands, proceed with rest of the physical examination, and perform the examination of the leg ulceration last.

ANS: C The examiner should wear gloves when the potential contact with any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. Although the nurse should wash his or her hands, there is no need to contact the physician at this point. The nurse should wash his or her hands immediately if they come into contact with bodily fluids and then apply gloves and continue the examination. The nurse should not change the order of the examination as an examiner should stick to his/her established system of examination so avoid omissions. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

What information obtained by the nurse regarding a patient's skin should the nurse record in the patient's health history? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm.

ANS: C The purpose of the health history is to collect subjective data, or what the person says about him or herself, so should be limited to patient statements that the person says were or were not present. Skin appears dry, no lesions are obvious, and lesions noted on the lateral aspect of the right arm are all objective data, or things that nurse observed. The purpose of the health history is to collect subjective data, or what the person says about him or herself, so should be limited to patient statements that the person says were or were not present. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. "Your atrial dysrhythmias are under control." b. "You have pitting edema and mild varicosities." c. "Your pulse is 80 beats per minute, which is within the normal range." d. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs in your lungs."

ANS: C The sharing of some information builds rapport, as long as the patient is able to understand the terminology. Options A, B, and D use terminology that the patient may not understand. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

During an interview, a woman says, "I have decided that I can no longer allow my children to live with their father's violence, but I just can't seem to leave him." Using interpretation, which would be the best response by the nurse? a. "You are going to leave him?" b. "If you are afraid for your children, then why can't you leave?" c. "It sounds as if you might be afraid of how your husband will respond." d. "It sounds as though you have made your decision. I think it is a good one."

ANS: C The statement "It sounds as if you might be afraid of how your husband will respond" is linking events, making associations, and implying cause, which are what occur in interpretation. Interpretation also recognizes feelings and helps the person understand his or her own feelings in relation to the verbal message. The other statements do not reflect interpretation. The statement "You are going to leave him?" is a direct question, not an interpretation. The statements "If you are afraid for your children, then why can't you leave?" and "It sounds as though you have made your decision. I think it is a good one" do not recognize the person's feelings or link events, make associations, or imply cause. In addition, in the latter statement the nurse is providing his or her opinion which is inappropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen.

ANS: C The thickness of the person's body wall will be a factor. The nurse needs a stronger percussion stroke for people with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this? a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic.

ANS: C To assess new memory, the nurse should ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person's ability to lay down new memories and is a highly sensitive and valid memory test. The FACT test, describing his first job, or describing the television show he was watching before coming to the clinic, does not test new memory. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

A patient tells the nurse that he is allergic to penicillin. What is the best response by the nurse? a. "Are you allergic to any other drugs?" b. "How often have you received penicillin?" c. "Describe what happens to you when you take penicillin." d. "I'll write your allergy on your chart so you won't receive any penicillin."

ANS: C When a person states he or she has an allergy, the nurse should note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). Before asking the patient about other allergies, the nurse should find out the patient's reaction to penicillin. Asking how often the patient has received penicillin is not necessary. Before documenting that a patient is allergic to a medication, the nurse should find out the reaction to it to determine if it is a true allergy or an unpleasant side effect. Both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing) should be recorded. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? a. "Do you have a weapon?" b. "How do other people treat you?" c. "Are you feeling so hopeless that you feel like hurting yourself now?" d. "People often feel hopeless, but the feelings resolve within a few weeks."

ANS: C When the person expresses feelings of hopelessness, despair, or grief, assessing the risk for physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse says to a patient, "I know it may be hard, but you should do what the doctor ordered because she is the expert in this field." Which statement is correct about the nurse's comment? a. It is inappropriate because it shows the nurse's bias. b. It is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.

ANS: C Using authority responses promotes dependency and inferiority. Avoiding the use of authority is best. Although the health care provider and patient do not have equal professional knowledge, both have equally worthy roles in the health process. The other statements are not correct. The comment "I know it may be hard, but you should do what the doctor ordered because she is the expert in this field" by the nurse does not show bias. In addition, not all members in the health care field are considered experts and using authority should be avoided. Although the health care professional may have more professional knowledge than the patient, both have equally important roles since the patient must make the final decision about his or her health. Using authority responses promotes dependency and inferiority and avoiding the use of authority is best. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

During an examination of a preschool child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the child's full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

ANS: D Preschoolers' communication is direct, concrete, literal, and set in the present. Therefore, health care providers should use short, simple sentences with a concrete explanation for any unfamiliar equipment that will be used on the child. Preschoolers are animistic; they imagine inanimate objects can come alive and have human characteristics. Thus a blood pressure cuff can wake up and bite or pinch. Preschoolers are animistic; they imagine inanimate objects can come alive and have human characteristics. Thus, the nurse should not say that the blood pressure cuff will give her arm a hug, that it is asleep, or that give it a name as those are humanistic characteristics and the blood cuff could wake up or come alive. Therefore, health care providers should use short, simple sentences with a concrete explanation for any unfamiliar equipment that will be used on the child. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

ANS: B A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

ANS: D The reason for seeking care is a brief spontaneous statement in the person's own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the person's exact words. Options A, B, and C do not contain the patient's exact words in quotations regarding the reason they are seeking care. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

During an examination, the nurse notices a patterned injury on a patient's back. What would cause such an injury? a. Blunt force b. Friction abrasion c. Stabbing from a kitchen knife d. Whipping from an extension cord

ANS: D A patterned injury is an injury caused by an object that leaves a distinct pattern on the skin or organ. The other actions do not cause a patterned injury. Blunt force often causes a hematoma. A friction abrasion is a wound caused by rubbing the skin or mucous membrane, like a rug burn. Stabbing from a kitchen knife would result in a penetrating, sharp, cutting injury that is deeper than it is wide. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

During an assessment, the nurse asks a female patient, "How many alcoholic drinks do you have a week?" Which answer by the patient would indicate at-risk drinking? a. "I may have one or two drinks a week." b. "I usually have three or four drinks a week." c. "I'll have a glass or two of wine every now and then." d. "I have eight to ten drinks a week, but I never get drunk."

ANS: D According to the Centers for Disease Control and Prevention, having eight or more drinks a week or four or more drinks per occasion is considered at-risk drinking for women. For women, having seven or more drinks a week or three or more drinks per occasion is considered at-risk drinking, according to the National Institute on Alcohol Abuse and Alcoholism. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. "Do you smoke?" b. "What is your religion?" c. "Do you have a history of heart disease?" d. "How many years have you lived in the United States?"

ANS: D Asking questions about a person's country of ancestry, years in the United States, etc. allows the nurse to assess a person's heritage. Simply asking about one's religion, smoking history, or health history does not reflect heritage. Simply asking about one's religion, smoking history, or health history does not reflect heritage. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

A pregnant woman is interested in breastfeeding her baby and asks several questions about the topic. Which statement by the nurse is appropriate? a. "Babies who are breastfed often require supplemental vitamins." b. "Breastfeeding is best when also supplemented with bottle-feedings." c. "Breastfeeding is recommended for infants for the first 2 years of life." d. "Breast milk provides the nutrients necessary for growth, as well as natural immunity."

ANS: D Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development, as well as natural immunity. The other statements are not correct.

The nurse is conducting an interview with an adult male patient. Which statement made by the patient indicates an alcohol use disorder? a. "I crave alcohol but have successfully cut down on my alcohol consumption." b. "I've been late to work a few times so now I limit myself to 2 drinks/day and stick to it." c. "I usually stay out longer and drink more than I intended but I still make it into work on time." d. "I have a strong urge to drink and I've tried to stop drinking several times but it doesn't last long.'

ANS: D Craving of having a strong desire or urge to use alcohol and having a persistent desire or unsuccessful efforts to cut down on alcohol consumption are two of the diagnostic criteria for an alcohol use disorder. The diagnostic criterion for an alcohol use disorder is the manifestation of at least two characteristics listed in Table 6.2. Although craving alcohol is a manifestation, the patient appears to be able to cut down on consumption. If he had several unsuccessful efforts to cut down or quit drinking, that would have been a manifestation of a drinking problem. Although failure to fulfill major role obligations at work (such as arriving on time), home, or school is a manifestation of a problem, the patient appears able to successfully limit drinks to 2/day which for a male is not an at-risk behavior. Although drinking larger amounts or over an extended period of time is a manifestation of an alcohol use disorder, the patient appears to be able to fulfill major role obligations such as getting to work on time. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a. Form a committee to conduct research studies. b. Post published research studies on the unit's bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies.

ANS: D Facilitating support for EBP includes teaching the nurses how to conduct electronic searches and time to go to the library. However, the best method to help that staff incorporate evidence-based clinical decision making into their practice would be to teach them how to conduct electronic literature searches for pertinent studies may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. Although allowing time for nurses to visit the library may help to support evidence-based questions, time to do so may not be available for many nurses. A better method to facilitate support for EBP would be teaching the nurses how to conduct electronic searches. Just posting published research studies on the unit's bulletin board does not facilitate EBP, as not all published research is valid or pertinent to the nurses' practice. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. MSC: Client Needs: Safe and Effective Care Environment: Management of Care

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which of these questions? a. "How are things going with the trial?" b. "How are things going with your job?" c. "Tell me about your recent engagement!" d. "Are you having any disturbing dreams?"

ANS: D Following a traumatic event outside the range of usual human experience that involves actual or threatened death or violence, such as rape, many people experience posttraumatic stress disorder (PTSD). One of the symptoms of PTSD is sleep problems. With PTSD the person relieves the trauma many times, intrusively and unwillingly. The same feelings of helplessness, fear, or horror recur. Avoidance of any trigger associated with the trauma occurs, and the person has hypervigilance, sleep problems, and difficulty concentrating, leading to feelings of being permanently damaged. The nurse should assess for symptoms of PTSD and options A, B, and C do not assess for those symptoms. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. "I broke my right leg in a car accident 2 weeks ago." b. "The pain is decreasing, but I still need to take acetaminophen." c. "I check the color of my toes every evening just like I was taught." d. "I'm able to transfer myself from the wheelchair to the bed without help."

ANS: D Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues. Statements such as "I broke my right leg in a car accident 2 weeks ago," "the pain is decreasing, but I still need to take acetaminophen," or "I check the color of my toes every evening just like I was taught" are statements concerning health or illness issues and not a person's self-care or functional ability. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Child's birth weight b. Age at which he crawled c. Whether the child has had the measles d. Child's reactions to previous hospitalizations

ANS: D How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure. The child's weight at birth, age at which he crawled, or whether or not had the measles is not information needed for the upcoming surgery. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, "Yes, I've used marijuana at parties with my friends." What is the next question the nurse should ask? a. "Who are these friends?" b. "Is this a regular habit?" c. "Do your parents know about this?" d. "When was the last time you used marijuana?"

ANS: D If a patient admits to the use of illicit substances, then the nurse should ask, "When was the last time you used drugs?" and "How much did you take that time?" The other questions may be considered accusatory and are not conducive to gathering information. Asking the person who the friends are, if it's a regular habit, and if the parents know about it can be considered accusatory and are not conducive to gathering necessary information. Instead, if a patient admits to the use of illicit substances, the nurse should ask, "When was the last time you used drugs?" and "How much did you take that time?" DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

In which situation is it most appropriate for the nurse to perform a focused or problem-centered history? a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for a scheduled surgery. d. Patient in an outpatient clinic has cold and influenza-like symptoms.

ANS: D In a focused or problem-centered database, the nurse collects a "mini" database, which is smaller in scope than the completed database. This mini database primarily concerns one problem, one cue complex, or one body system. A complete database should be conducted for a patient being admitted to a long-term care facility or being admitted for a scheduled surgery. An emergency database should be conducted for a patient with sudden and severe shortness of breath. MSC: Client Needs: Safe and Effective Care Environment: Management of Care

During an interview, a woman has answered "yes" to two of the Slapped, Threatened, and Throw (STaT) questions. What should the nurse say next? a. "So you were abused?" b. "Do you know what caused this abuse?" c. "I need to report this abuse to the authorities." d. "Tell me about the abuse in your relationship."

ANS: D In any case of suspected abuse an open-ended question or statement is useful. If a woman answers "yes" to any of the Slapped, Threatened, and Throw (STaT) questions, then the nurse should ask a question such as "Tell me about the abuse in your relationship". This is a good way to start and is designed to assess how recent or frequent the abuse and its severity. If a woman answers "yes" to any of the Abuse Assessment Screen questions, then the nurse should ask questions designed to assess how recent and how serious the abuse was. Asking the woman an open-ended question, such as "tell me about this abuse in your relationship" is a good way to start. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a. Avoid palpation of reportedly "tender" areas because palpation in these areas may cause pain. b. Palpate a tender area quickly to avoid any discomfort that the patient may experience. c. Start the assessment with deep palpation, while encouraging the patient to relax and take deep breaths. d. Begin the assessment with light palpation to detect surface characteristics and to accustom the patient to being touched.

ANS: D Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. "I know my name is John. I couldn't tell you where I am. I think it is 2010, though." b. "I know my name is John, but to tell you the truth, I get kind of confused about the date." c. "I know my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date." d. "I know my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2010."

ANS: D Many aging people experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging people oriented if they generally know where they are and the present period. They should be considered oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., hospital) and the name of the town. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is performing a physical assessment on a newly admitted patient. Which is an example of objective information obtained during the physical assessment? a. Patient's history of allergies b. Patient's use of medications at home c. Last menstrual period 1 month ago d. 2 × 5 cm scar on the right lower forearm

ANS: D Objective data is the patient's record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. A patient's history of allergies, use of medications at home, and date of last menstrual periods are all subjective data. MSC: Client Needs: Safe and Effective Care Environment: Management of Care

A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. "How is your family?" b. "How is your job?" c. "Tell me about your hypertension." d. "How has your health been since your last visit?"

ANS: D Open-ended questions are used for gathering narrative information. This type of questioning should be used to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. "How is your family" and "How is your job" are small talk and do not provide any information on the patient's health. The nurse should not begin with asking about the patient's hypertension but should begin the interview with a more general open-ended question. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. How should the nurse proceed? a. Palpate over the area for increased pain and tenderness. b. Ask the child to take shallow breaths, and percuss over the area again. c. Refer the child to a specialist because of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination.

ANS: D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child's lung. There is no need to palpate for increased pain and tenderness; ask the child to take shallow breaths and percuss again; or refer the child to a specialist as loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child's lung. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality? a. Belief in and the worship of God or gods b. Being closely tied to one's ethnic background c. Attendance at a specific church or place of worship d. A connection with something larger than oneself and belief in transcendence

ANS: D Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Belief in and the worship of God or gods and attendance at a specific church or place of worship apply to religion. Being closely tied to one's ethnic background is not a concept of spirituality or religion. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

During an assessment, the nurse uses the CAGE test. The patient answers "yes" to two of the questions. What could this be indicating? a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance-abuse assessment.

ANS: D The CAGE test is known as the "cut down, annoyed, guilty, and eye-opener" test. If a person answers "yes" to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance-abuse assessment. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The nurse is preparing to auscultate the abdomen. How should the nurse proceed? a. Warm the endpiece of the stethoscope by placing it in warm water. b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c. Ensure that the bell side of the stethoscope is turned to the "on" position. d. Check the temperature of the room and offer blankets to the patient if he or she feels cold.

ANS: D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner's hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? a. "Hello, Nancy, my name is Nurse C." b. "Mrs. H., my name is Nurse C. How are you?" c. "Hello, Mrs. H., my name is Nurse C. It sure is cold today!" d. "Mrs. H., my name is Nurse C. I'll need to ask you a few questions about what happened."

ANS: D The nurse should address the person by using his or her surname as automatic use of the first name is too familiar for most adults and lessens dignity. The nurse should introduce him or herself and give the reason for the interview. Friendly small talk is not needed to build rapport. The nurse should not initially address a patient by their first name as automatic use of the first name is too familiar for most adults and lessens dignity. Statements such as "How are you today" and "It sure is cold out today" are small talk and are not necessary to build rapport. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. "Mr. Y., at your age, surely you have been hospitalized before!" b. "Mr. Y., I just need permission to get your medical records from County Medical." c. "Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?" d. "Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?"

ANS: D The nurse should use direct questions after the person's opening narrative to fill in any details he or she left out. The nurse also should use direct questions when specific facts are needed, such as when asking about past health problems or during the review of systems. The nurse should not assume that a patient has been hospitalized based on their age and stating such is inappropriate. Getting the patient's medical records from another facility is not necessary during the interview process. Asking the patient to tell you more about hospitalization in order to complete missing interview data is not necessary; instead, direct questions should be asked when specific facts are needed. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. Which is the best response by the nurse? a. "Stop that immediately!" b. "Oh, you are too funny. Let's keep going with the interview." c. "Do you really think I would be interested?" d. "It makes me uncomfortable when you talk that way. Please stop."

ANS: D The nurse's response must make it clear that she is a health professional who can best care for the person by maintaining a professional relationship. At the same time, the nurse should communicate that he or she accepts the person and understands the person's need to be self-assertive but that sexual advances cannot be tolerated. Saying "Stop that immediately," "Oh, you are too funny. Let's keep going with the interview," or "Do you really think I would be interested?" do not acknowledge how the patient's actions make the nurse feel and do not make it clear that they must maintain a professional relationship in order to best care for the patient. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

Which statement best describes a proficient nurse? a. Has little experience with a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. Sees actions in the context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient.

ANS: D The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see how today's nursing actions can apply to the point the nurse wants the patient to reach at a future time. A nurse that has little experience with a specified population and uses rules to guide performance is a novice nurse. A nurse that has an intuitive grasp of a clinical situation and quickly identifies the accurate solution is an expert nurse. Seeing actions in the context of daily plans for patients describes competency or a competent nurse. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: General

A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. "It is a sharp, burning pain in my stomach." b. "I also have the sweats and nausea when I feel this pain." c. "I think this pain is telling me that something bad is wrong with me." d. "This pain happens every time I sit down to use the computer."

ANS: D The setting describes where the person is or what the person is doing when the symptom starts. Describing the pain as "sharp and burning" reflects the character or quality of the pain; stating that the pain is "telling" the patient that something bad is wrong with him reflects the patient's perception of the pain; and describing the "sweats and nausea" reflects associated factors that occur with the pain. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which response by the nurse would be appropriate? a. "How does your family react to your pain?" b. "The pain must be terrible. You probably pinched a nerve." c. "I've had back pain myself, and it can be excruciating." d. "How would you say the pain affects your ability to do your daily activities?"

ANS: D The symptom of pain is difficult to quantify because of individual interpretation. It is important to find out the meaning of the pain to the person by asking how it affects daily activities. The nurse needs to find out the patient's perception or meaning of the pain, rather than how the family reacts to it. The nurse should avoid the use of adjectives when discussing the person's pain, should not give his or her opinion of the cause, or focus on their own experience with pain. Instead, the nurse should ask the patient how the pain affects his or her daily activities. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best description of this patient's problem? a. Echolalia b. Global aphasia c. Broca's aphasia d. Wernicke's aphasia

ANS: D This type of communication illustrates Wernicke's or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well-articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another person's words or phrases. With global aphasia, spontaneous speech is absent or reduced to a few stereotyped words or sounds and comprehension is absent or reduced to only a person's own name and a few select words. With Broca's aphasia the person can understand language but cannot express himself using words or language. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

During a home visit, the nurse notices that an older adult woman is caring for her bedridden husband. The woman states that this is her duty, she does the best she can, and her children come to help when they are in town. Her husband is unable to care for himself, and she appears thin, weak, and exhausted. The nurse notices that several of his prescription medication bottles are empty. What term best describes this situation? a. Physical abuse b. Financial neglect c. Psychological abuse d. Unintentional physical neglect

ANS: D Unintentional physical neglect may occur, despite good intentions, and is the failure of a family member or caregiver to provide basic goods or services. Physical abuse is defined as violent acts that result or could result in injury, pain, impairment, or disease. Financial neglect is defined as the failure to use the assets of the older person to provide services needed by him or her. Psychological abuse is defined as behaviors that result in mental anguish. The scenario in the question is an example of unintentional physical neglect. Unintentional physical neglect may occur, despite good intentions, and is the failure of a family member or caregiver to provide basic goods or services. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

In obtaining a review of systems on a "healthy" 7-year-old girl, what should the health care provider be sure to include? a. Last glaucoma examination b. Frequency of breast self-examinations c. Date of her last electrocardiogram d. Limitations r/t her involvement in sports activities

ANS: D When completing a review of the cardiovascular system for a child the health care provider should ask whether there are any congenital heart defects, history of murmurs, or cyanosis as well as if any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age. The date of the last glaucoma examination, frequency of breast self-examinations, and date of last electrocardiogram are not appropriate questions for a review of systems for a "healthy" 7-year-old. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. What action should the nurse take in this situation? a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patient's verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings.

ANS: D When nonverbal and verbal messages are congruent, the verbal message is reinforced. When they are incongruent, as in this case, the nonverbal message tends to be the true one because it is under less conscious control. The other statements are not true. When nonverbal and verbal messages are incongruent, as in this case, the nonverbal message tends to be the true one because it is under less conscious control. Thus, asking someone who knows the patient well to help interpret this discrepancy; focusing on the patient's verbal message, and trying to ignore the nonverbal behaviors; and trying to integrate the verbal and nonverbal messages and then interpret them as an average are inappropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself d. Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

ANS: D When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk for physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.

Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself d. Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

ANS: D When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk for physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response by the nurse? a. "Maybe she is just teething." b. "I will check her ear for an ear infection." c. "Are you sure she is really having pain?" d. "Describe what she is doing to indicate she is having pain."

ANS: D With a very young child, the parent is asked, "How do you know the child is in pain?" A young child pulling at his or her ears should alert parents to the child's ear pain. Statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, "I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!" Which of these responses by the nurse uses empathy? a. "You feel alone." b. "You can't believe he left you alone?" c. "It must be so hard to care for a child all alone." d. "I would be angry, too; raising a child alone is no picnic."

An empathetic response recognizes the feeling and puts it into words. It names the feeling, allows its expression, and strengthens rapport. Some empathetic responses are, "This must be very hard for you," "I understand," or simply placing your hand on the person's arm. Simply reflecting the person's words or agreeing with the person is not an empathetic response. Simply reflecting the person's words by saying "You feel alone" or "You can't believe he left you alone", or agreeing with the person by saying "I would be angry, too; raising a child alone is no picnic" are not empathetic responses. They do not name the feeling, allow its expression or strengthen rapport.

The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group? a. Maintaining adequate fat and caloric intake is important for a 1-year-old child. b. The recommended dietary allowances for an infant are the same as for an adolescent. c. The baby's growth is minimal at this age; therefore, caloric requirements are decreased. d. The baby should be placed on skim milk to decrease the risk for coronary artery disease when he or she grows older.

Because of rapid growth, especially of the brain, both infants and children younger than 2 years of age should not drink skim or low-fat milk or be placed on low-fat diets. Fats (calories and essential fatty acids) are required for proper growth and central nervous system development. The recommended dietary allowances for infants and adolescents are not the same. There is a great deal of growth in the first 4 years of life both in length height and in the brain. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood pressure checks since she changed medications 2 months ago. Which is the most appropriate action for the nurse to take? a. Collect a follow-up database and then check the patient's blood pressure. b. Ask the patient to read her health record and indicate any changes since her last visit. c. Check the patient's blood pressure. d. Obtain a complete health history on the patient before checking her blood pressure.

ans: a A follow-up database is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation. Asking the patient to read her health history and indicate any changes since her last visit is not appropriate. Just checking the patient's blood pressure without following up on or assessing for any changes in the patient's condition is inappropriate. It is not necessary to conduct a complete health history as one was conducted 2 months ago. Rather a follow-up assessment regarding the patient's blood pressure and factors associated with it are necessary. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. What is the best description of this patient's condition? a. A snake phobia b. A hypochondriac c. An obsession with snakes d. A delusion that snakes are harmful stemming from an early traumatic incident involving snakes

ans:A This is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. The situation in the question is not an example of hypochondria, an obsession, or a delusion. A hypochondriac is a person who is morbidly worried about his/her own health and/or feels sick with no actual basis for that assumption. An obsession is an unwanted, persistent thought or impulse in which logic will not purge him/her from his/her consciousness and is intrusive and senseless. A delusion is a firm, fixed, false belief that is irrational and that a person clings to despite objective evidence to the contrary. Instead, the situation in the question is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity