Jensen Chapter 2
Physical appearance, facial expression, posture and positioning in relation to the patient, gestures, eye contact, tone of voice, and use of touch are all important components of a. nonverbal communication b. empathy c. caring
a. nonverbal communication
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? a. value-belief b. self-perception c. role-relationship d. coping-stress-tolerance
a. value-belief
For any past illnesses, include a a. medical diagnosis b. treatment c. the treatment outcomes d. date e. all of the above
e. all of the above
Interpreters are chosen on the basis of all EXCEPT a. language b. dialect c. gender (for sensitive subjects) d. social status (if this is likely to be an issue) e. race
e. race
Often in social situations, people use ________________. Probably the most common example is false reassurance to minimize uncomfortable feelings. a. nontherapeutic casual responses b. therapeutic responses c. formal responses
a. nontherapeutic casual responses
Review of systems (ROS)
is a series of questions about all body systems that helps to reveal concerns as part of a comprehensive health assessment
Closed-ended or direct questions are best for specific information that yields ____________, such as "Do you have a history of heart disease?"
yes-or-no answers
Usually, a goal of __________ is acceptable. Pain in excess of this will be treated.
zero to mild pain (0 to 3 on a 10-point scale)
What are the (4) phases of the interview process?
1. Preinteraction phase 2. Beginning phase 3. Working phase 4. Closing phase
Nurses use a mnemonic to remember the elements that are important to assess for the presenting symptom. COLDSPA
C: Character O: Onset L: Location D: Duration S: Severity P: Pattern A: Associated factors/how it affects the patient
True or False. Patients are always able to read or write in their language.
False, Patients may not be able to read or write in their language.
If a patient uses another primary language,
obtain an interpreter
Nurses use a mnemonic to remember the elements that are important to assess for the presenting symptom. OLDCARTS
O: Onset L: Location D: Duration C: Character A: Associated or aggravating factors R: Relieving factors T: Timing S: Severity
Nurses use a mnemonic to remember the elements that are important to assess for the presenting symptom. PQRSTU P: Provocative or palliative Q: R: Region S: Severity T: Timing U:
Quality, Understanding patient perception
True or False. For hospitalized patients, you must reconcile all medication lists with medications taken regularly at home so that patients continue using the correct drugs
True, For hospitalized patients, you must reconcile all medication lists with medications taken regularly at home so that patients continue using the correct drugs
True or False. Visiting patients beyond your role of providing patient care also breaks professional boundaries.
True, Visiting patients beyond your role of providing patient care also breaks professional boundaries.
___________ questions require patients to give more than yes-or-no answers. They are broad and yield responses in the patient's own words. a. Open-ended b. Closed-ended c. Intermediate
a. Open-ended
Which option is more inclusive, sensitive, and ultimately better question? a. "Do you live alone or with someone?" b. "Are you single, married, or divorced?"
a. "Do you live alone or with someone?"
You should avoid _______ questions because patients may find them difficult to answer and view such questions as accusatory or judgmental a. "why" b. "how" c. "when"
a. "why"
The nurse recognizes that an example of subjective data would include: a. A pain rating of 7 b. 100 cc of emesis c. Scratching d. 2-inch scar right lower abdomen
a. A pain rating of 7
___________ requires that you constantly decode messages, including thoughts, words, opinions, and emotions. a. Active listening b. Passive listening c. Empathy
a. Active listening
__________ is a complex, ongoing, interactive process that forms the basis for building interpersonal relationships a. Communication b. Bonding c. Giving
a. Communication
______________ you use responses that encourage patients to say more and continue the conversation. Examples: You may nod your head, or say, "Um-hum," "Yes," or "Go on" to cue patients to keep talking. Another technique is to let patients know that their thoughts and feelings are common, normal experiences and give them permission to discuss them. a. Elaboration (facilitation) b. Restatement c. Reflection
a. Elaboration (facilitation)
Which type of health history is described below? - Collect most important information until client is stable - Elicit reason for seeking care, current health problems, medications, and allergies - Focuses on gathering information so that interventions can resolve the immediate problem - Assessments and interventions are concurrent. a. Emergency b. Focused c. Comprehensive
a. Emergency
What is described below? - focus on the effects of health or illness on a patient's quality of life. - By using this approach, you can assess the strengths of patients as well as areas needing improvement a. Functional health patterns b. Objective data c. Activities of daily living (ADLs)
a. Functional health patterns
A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information? a. General b. Appetite c. Rest and sleep d. Gastrointestinal
a. General
Which phase of the interview process is described below? - Reviewing the medical record chronologically to detect patterns of illness such as declining functional status and to identify how things fit together a. Preinteraction Phase b. Beginning Phase c. Working Phase d. Closing Phase
a. Preinteraction Phase
When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following? a. Quote the client's words. b. Summarize the client's words. c. Paraphrase the client's words. d. Describe the client's concerns and health goals.
a. Quote the client's words.
__________ relates to the content of the communication. You make a simple statement, usually with the patient's own words. The purpose is to ask the patient to elaborate. a. Restatement b. Active listening c. Sympathy
a. Restatement
While discussing health patterns, a client says, "I hate my job." In which category should the nurse document and further assess this information? a. Role-relationship b. Vocation/occupation c. Coping-stress-tolerance d. Self-perception/self-concept
a. Role-relationship
In many cultures, mental health disorders carry great stigma, so patients may describe psychosocial difficulties as a. a lack of sleep or as feeling tired b. feelings of happiness c. feeling energized
a. a lack of sleep or as feeling tired
You should suspect _________if injuries are inconsistent with explanations, if the story changes over time, if the patient has delayed getting treatment, if there is a past history of injuries or accidents, if there is associated drug or alcohol abuse, or if there is a history of mental illness. Commonly, the patient's abuser is overly protective, may refuse to leave the room, or dominates the interview. Abused children may be overly attentive in an attempt to please the parent or guardian a. abuse b. stealing c. drug use
a. abuse
Psychosocial development and cognitive stage is part of assessment for ____________because even some adults have delays and do not progress as expected. a. all age groups b. 12-24 c. early childhood
a. all age groups
The purpose of taking the health history is to a. collect subjective data b. collect objective data c. validate information
a. collect subjective data
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? a. create a genogram b. document it in a narrative note c. include in the past medical history d. consider using it when planning care
a. create a genogram
Talking openly with the patient about ___________may not be acceptable because it is considered disrespectful, bad luck, or causes loss of hope in some culture a. death and dying b. birth c. love
a. death and dying
Health History If a patient replies by giving a medical diagnosis, such as "heart attack," encourage the patient to a. describe the symptoms b. speak about other ailments c. list signs
a. describe the symptoms
If any pregnancies are incomplete, a. document the reason b. do not list it c. ignore it
a. document the reason
Gender identity ______ define an individual's sexual orientation. a. does not b. does c. sometimes
a. does not
To facilitate optimal eye contact, you need to be at a. eye level with the patient b. above eye level with the patient c. below eye level with the patient
a. eye level with the patient
A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the a. focused assessment b. comprehensive health history c. follow-up history d. emergency history
a. focused assessment
Inform the patient at the beginning of the interview that you must report a. harm to self or others to get needed assistance b. only harm to self c. only harm to others
a. harm to self or others to get needed assistance
If information differs from past descriptions, or if details change each time, the patient considered an __________. a. inaccurate historian b. reliable historian c. primary data source
a. inaccurate historian
During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? a. neurologic b. cardiovascular c. musculoskeletal d. peripheral vascular
a. neurologic
Using children in the family, other relatives, or close friends as interpreters violates _________ because patients may not want to share personal information with relatives or friends. a. privacy laws b. personal space c. informed consent
a. privacy laws
The ___________ is a brief statement, usually in the patient's own words, about why he or she is making the visit. a. reason for seeking care b. biographical data c. primary data
a. reason for seeking care
In many settings, patients complete comprehensive forms independently in advance. You then a. review the form and ask questions during the interview b. transfer the information to a primary care provider c. consider the information complete and accurate
a. review the form and ask questions during the interview
You need a comfortable _________ to be aware of your own biases, values, personality, cultural background, and communication style. a. self-concept b. level of knowledge c. self-respect
a. self-concept
Family roles is defined as a a. set of beliefs about or expectations of male and female behavior and experiences within the family b. firm beliefs about sexual orientation c. a set of beliefs about the female gender
a. set of beliefs about or expectations of male and female behavior and experiences within the family
The review of system contains a. subjective data b. objective data c. both
a. subjective data
Patients tend to think in ___________, thus delaying their responses. a. their native language and translate b. the dominant language c. the dominant language and speak their native language
a. their native language and translate
When asking about allergies, it is essential to note the ____________, such as rash, throat swelling, difficulty breathing, or anaphylactic shock. a. type of response b. location of response c. duration of response
a. type of response
Your posture must be upright but relaxed and open; avoid "closed" positions, such as crossed arms, which may signal to patients that you are a. uninterested in them and their information b. interested in them c. ready to receive information
a. uninterested in them and their information
Activities of daily living (ADLs)
ability to perform self-care activities
Chart events a. in steps b. chronologically c. by severity
b. chronologically
The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use? a. During the review of systems b. After assessing for cigarette use c. Before assessing for vaccinations d. While completing the family history
b. After assessing for cigarette use
Which phase of the interview process is described below? - Introduce your name and state purpose of interview - Ask what the patient likes to be called - Make sure the client has privacy (close drapes/door) a. Preinteraction Phase b. Beginning Phase c. Working Phase d. Closing Phase
b. Beginning Phase
___________ is important when the patient's word choice or ideas are unclear. For example, you may state, "Tell me what you mean by the evil eye." a. Restatement b. Clarification c. Reflection
b. Clarification
____________ means the ability to perceive, reason, and communicate understanding of another person's feelings without criticism. a. Sympathy b. Empathy c. Caring
b. Empathy
Which type of health history is described below? - Ask questions that relate to the current situation - Do not perform a complete review of systems a. Emergency b. Focused c. Comprehensive
b. Focused
Communication etiquette -----> code of conduct _________________ -----> polite and courteous manners that show respect for others a. Respect b. Intercultural communication c. Empathy
b. Intercultural communication
During the review of systems within the comprehensive health history, the nurse notes that a client has multiple previous injuries and accidents. Which of the following issues is a priority in the nurse's assessment? a. Assess the client's gait and balance b. Investigate the possibility of physical abuse c. Inquire about the client's substance use d. Complete the Cage Questionnaire
b. Investigate the possibility of physical abuse
____________ may be sensitive issues for some patients. In such cases, explain the reason for asking about them a. Financial status b. Occupation and insurance c. Martial Status
b. Occupation and insurance
A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point? a. Transition b. Summarization c. Reassurance d. Termination
b. Summarization
___________ happens at the end of the interview, during the closure phase. You review and condense important information into two or three of the most important findings. a. Reflection b. Summarizing c. Clarification
b. Summarizing
A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? a. Standing while the client is seated b. Using a moderate amount of eye contact c. Sitting across the room from the client d. Minimizing facial expressions
b. Using a moderate amount of eye contact
Some patients may confuse an adverse effect or adverse reaction with an allergy; these should a. ignored b. also be noted c. list with priority
b. also be noted
Subjective understanding, perceptions, and other variables greatly influence the actual a. the medium of the message b. decoding of the message c. transcription
b. decoding of the message
Giving ______________ - effectively ends communication with the patient - unconsciously indicate to patients that their concerns are not worth discussing. - enhances anxiety, which can increase a patient's needs in other areas, such as pain medication, and diminish trust. - Examples are, "It won't hurt," or "Don't worry—it will be all right." a. unwanted advice b. false reassurance c. sympathy
b. false reassurance
A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice? a. risk factors b. health maintenance c. screening test completion d. compliance with treatment
b. health maintenance
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? a. physical examination b. health maintenance c. personal and social history d. review of systems
b. health maintenance
Depending on the health care setting, personnel at a front desk or admissions department often collect demographic data from patients, including all EXCEPT a. name b. income level c. date of birth d. address e. billing information
b. income level
Assess that younger patients are appropriately developing abstract thinking skills, and evaluate older patients for any signs of __________. a. knowledge deficient b. memory decline c. negative personality traits
b. memory decline
Identify the purpose of each medication because some drugs have a. mild side effects b. more than one use c. no effect
b. more than one use
Allergies must be appropriately noted in the chart, and the hospitalized patient must have a a. name tag b. name band applied noting the allergy c. simple note in chart
b. name band applied noting the allergy
In therapeutic communication, the interaction focuses on the a. patient and family b. patient and the patient's concerns c. the health care provider
b. patient and the patient's concerns
A _____________ provides information that is consistent with existing records and is comprehensive in scope. a. inaccurate historian b. reliable historian c. primary data source
b. reliable historian
Subjective data are based on a. observable signs b. signs and symptoms c. things that can be experienced by the senses
b. signs and symptoms
For patients with limited knowledge of the English language, use ___________________. a. complex language b. simple and clear language, but do not raise your voice c. simple language in a loud voice
b. simple and clear language, but do not raise your voice
Health History contains a. objective data b. subjective data c. both a and b
b. subjective data
Empathy may be conveyed _____________. In some situations, such as death of a relative, you may exhibit empathy simply by holding a person's hand or offering a tissue. a. verbally b. verbally or nonverbally c. nonverbally
b. verbally or nonverbally
Which of the following questions would be most important for the nurse to ask first when obtaining the health history? a. "Do you have adequate health insurance coverage?" b. "Are you generally fairly healthy?" c. "What is your major health concern at this time?" d. "Did you bring all your medications with you?"
c. "What is your major health concern at this time?"
___________ encompasses your empathy for and connection with the patient. It includes the ability to demonstrate compassion, sensitivity, and patient-centered care a. Sympathy b. Empathy c. Caring
c. Caring
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative? a. Simple circle b. Simple square c. Circle with a cross d. Square with a cross
c. Circle with a cross
Which type of health history is described below? - Takes place during an annual physical examination, hospital admission, etc. - Includes demographic data, full reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas a. Emergency b. Focused c. Comprehensive
c. Comprehensive
___________ also refers to whether the pain is constant or intermittent, how long it lasts, and whether it goes completely away or cycles off and on. a. Aggravating factors b. Location c. Duration
c. Duration
___________ is creating the most accurate list of all medications a patient is taking and comparing that list against the physician's admission, transfer, or discharge orders. a. Check off b. Revitalization c. Medication reconciliation
c. Medication reconciliation
__________ is summarizing the main themes of communication. The conversation may be longer, in which a patient discusses several elements related to a topic. a. Restatement b. Active listening c. Reflection
c. Reflection
Which phase of the interview process is described below? - Collect data by asking specific questions - Chart the patient's history and health problems - Review completed forms with the patient - Ask follow-up questions and clarify information a. Preinteraction Phase b. Beginning Phase c. Working Phase d. Closing Phase
c. Working Phase
During the interview, it is important to a. have prolonged eye contact b. have no eye contact c. balance soft eye contact with brief glances away
c. balance soft eye contact with brief glances away
You can also use closed-ended questions (e.g., "Is your pain sharp or dull?") to help cue patients who a. have difficulty responding to an open-ended question b. have communication challenges, such as those with dementia or limited knowledge of English c. both a and b
c. both a and b
Parents, legal guardians, or other adult representatives serve as primary interview sources of health care information when patients are ________. Elderly patients may, in some cases, also have a legal guardian. a. 45-60 years old b. 12-24 years old c. children
c. children
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? a. sleep-rest b. activity-exercise c. coping-stress-tolerance d. self-perception/self-concept
c. coping-stress-tolerance
Usually, you collect ______________first and then elicit from the patient a complete description of the reason for seeking health care. a. geographic data b. biographical data c. demographic data
c. demographic data
The _________ includes vital information for assessment including history of present illness, past health history, functional health patterns, review of systems, and family history. a. physical assessment b. comprehensive history c. health history
c. health history
The best approach to allow a patient the opportunity to speak is to a. talk loudly b. make strong eye contact c. insert pauses
c. insert pauses
An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information? a. adult daughter controlling the interview b. unable to recall exact date of last surgery c. last surgery date validated by adult daughter d. confused regarding dates of surgical procedures
c. last surgery date validated by adult daughter
Sympathy is feeling what a patient feels. When you are being sympathetic, you are a. being therapeutic because you are listening to the patient b. being therapeutic because it focuses on the patient's perspective c. not being therapeutic because you are interpreting the situation as you perceive it
c. not being therapeutic because you are interpreting the situation as you perceive it
For female patients, note the obstetric history, including ____________. a. number of births (para) b. number of pregnancies (gravida) c. number of pregnancies (gravida) and number of births (para)
c. number of pregnancies (gravida) and number of births (para)
All of the following are occasions for using an interpreter EXCEPT a. admission assessment b. complex treatments c. routine procedures d.patient education e. informed consent f. discharge planning
c. routine procedures
Charts and information from family members are considered ______________. a. third data source d. tertiary data source c. secondary data source d. primary data source
c. secondary data source
You can use _____________ - to allow patients time to gather their thoughts and provide accurate answers - to communicate nonverbal concern - indicates that you are interested in what the person is saying - gives patients a chance to decide how much information to disclose. a. active listening b. reflection c. silence
c. silence
Record the reason for seeking care in the ____________; consider putting the statement in quotes. a. family history b. objective part of documentation c. subjective part of documentation
c. subjective part of documentation
Giving __________ is nontherapeutic in professional relationships because the advice is usually from your perspective, not the patient's. Because the advice is based on your experiences and opinions, it will not help the patient. a. false reassurance b. sympathy c. unwanted advice
c. unwanted advice
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is a. "Do you feel stress at work?" b. "How often do you feel stressed?" c. "Is stress a problem in your life?" d. "How do you manage your stress?"
d. "How do you manage your stress?"
Which phase of the interview process is described below? - Summarizing and stating what the two to three most important patterns or problems might be - Ask whether the patient would like to mention anything or needs anything else - If you are using a checklist, this is a good time to review it for completeness and to make notes about future interventions. a. Preinteraction Phase b. Beginning Phase c. Working Phase d. Closing Phase
d. Closing Phase
The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information? a. Initial information b. Review of systems c. Health patterns d. History of present illness
d. History of present illness
Include in the record any childhood illnesses with a. potentially lasting effects (e.g., polio, varicella) b. the common cold c. most recent immunizations for tetanus, pertussis, polio, measles, rubella, mumps, influenza, hepatitis A, B, and C, and pneumococcus d. a and c only
d. a and c only
After ensuring patient's safety, disclose information required to be reported by law, such as all of the following EXCEPT a. suicidal thoughts b. violence at home c. rape d. feelings of anger
d. feelings of anger
The individual patient is considered the _______________. a. third data source d. tertiary data source c. secondary data source d. primary data source
d. primary data source
Use ___________ when patients are straying from a topic and need redirection. It keeps the conversation on track without changing the subject. a. focusing b. reflection c. silence
focusing
Ask patients about current medications, including name, dose, route, and_________
frequency
Assess spirituality and belief systems during the___________ by asking questions related to values or beliefs
functional health screening
A common tool used to understand family patterns is the ________.
genogram
One in three adults older than 70 years has some type of
hearing loss
When the primary concern is psychiatric, you perform a complete __________.
mental health assessment
When taking the health history for a child, it is especially important to include __________________.
the pregnancy, birth, and perinatal histories
Social talking about the weather or news may put patients at ease in the beginning, but too much chatting—especially about religion, politics, gossip, or personal finances—is
unprofessional