Health Assessment Final JARVIS
When assessing aging adults, the nurse knows that one of the first things that should be
assessed before making judgments about their mental status is:
a. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities - ✔️✔️ANS: D
Age-related changes in sensory perception can affect mental status. For example,
vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and
depression. Hearing changes are common in older adults, which produces frustration,
suspicion, and social isolation and makes the person appear confused
A 20-year-old construction worker has been brought into the emergency department
with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the
mental status examination, the nurse should first assess the patient's:
a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities - ✔️✔️ANS: D
Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the
environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an
alteration in mood, affect, or language abilities.
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 Mrs. C."
b."Hello, Mrs. H., my name is Mrs. C. It sure is cold today!"
c."Mrs. H., my name is Mrs. C. How are you?"
,d."Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what
happened." - ✔️✔️ANS: D
Address the person by using his or her surname. The nurse should introduce him or
herself and give the reason for the interview. Friendly small talk is not needed to build
rapport.
During an interview, the nurse states, "You mentioned having shortness of breath. Tell
me more about that." Which verbal skill is used with this statement?
a.Reflection
b.Facilitation
c.Direct question
d.Open-ended question - ✔️✔️Answer: D
The open-ended question asks for narrative information. It states the topic to be
discussed but only in general terms. The nurse should use it to begin the interview, to
introduce a new section of questions, and whenever the person introduces a new topic.
The nurse is conducting an interview with a woman who has recently learned that she is
pregnant and who has come to the clinic today to begin prenatal care. The woman
states that she and her husband are excited about the pregnancy but have a few
questions. She looks nervously at her hands during the interview and sighs loudly.
Considering the concept of communication, which statement does the nurse know to be
most accurate? The woman is:
a.Excited about her pregnancy but nervous about the labor.
b.Exhibiting verbal and nonverbal behaviors that do not match.
c.Excited about her pregnancy, but her husband is not and this is upsetting to her.
d.Not excited about her pregnancy but believes the nurse will negatively respond to her
if she states this. - ✔️✔️ANS: B
Communication is all behaviors, conscious and unconscious, verbal and nonverbal. All
behaviors have meaning. Her behavior does not imply that she is nervous about labor,
upset by her husband, or worried about the nurse's response.
Receiving is a part of the communication process. Which receiver is most likely to
misinterpret a message sent by a health care professional?
a.Well-adjusted adolescent who came in for a sports physical
, b.Recovering alcoholic who came in for a basic physical examination
c.Man whose wife has just been diagnosed with lung cancer
d.Man with a hearing impairment who uses sign language to communicate and who has
an interpreter with him - ✔️✔️ANS: C
The receiver attaches meaning determined by his or her experiences, culture, self-
concept, and current physical and emotional states. The man whose wife has just been
diagnosed with lung cancer may be experiencing emotions that affect his receiving.
In an interview, the nurse may find it necessary to take notes to aid his or her memory
later. Which statement is true regarding note-taking?
a. Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
b. Note-taking allows the patient to continue at his or her own pace as the nurse records
what is said.
c. Note-taking allows the nurse to shift attention away from the patient, resulting in an
increased comfort level.
d.Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort. - ✔️✔️ANS: A
The use of history forms and note-taking may be unavoidable. However, the nurse must
be aware that note-taking during the interview has disadvantages. It breaks eye contact
too often and shifts the attention away from the patient, which diminishes his or her
sense of importance. Note-taking may also interrupt the patient's narrative flow, and it
impedes the observation of the patient's nonverbal behavior.
The nurse asks, "I would like to ask you some questions about your health and your
usual daily activities so that we can better plan your stay here." This question is found at
the __________ phase of the interview process.
a.Summary
b.Closing
c.Body
d.Opening or introduction - ✔️✔️ANS: D
When gathering a complete history, the nurse should give the reason for the interview
during the opening or introduction phase of the interview, not during or at the end of the
interview.
When assessing aging adults, the nurse knows that one of the first things that should be
assessed before making judgments about their mental status is:
a. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities - ✔️✔️ANS: D
Age-related changes in sensory perception can affect mental status. For example,
vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and
depression. Hearing changes are common in older adults, which produces frustration,
suspicion, and social isolation and makes the person appear confused
A 20-year-old construction worker has been brought into the emergency department
with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the
mental status examination, the nurse should first assess the patient's:
a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities - ✔️✔️ANS: D
Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the
environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an
alteration in mood, affect, or language abilities.
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 Mrs. C."
b."Hello, Mrs. H., my name is Mrs. C. It sure is cold today!"
c."Mrs. H., my name is Mrs. C. How are you?"
,d."Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what
happened." - ✔️✔️ANS: D
Address the person by using his or her surname. The nurse should introduce him or
herself and give the reason for the interview. Friendly small talk is not needed to build
rapport.
During an interview, the nurse states, "You mentioned having shortness of breath. Tell
me more about that." Which verbal skill is used with this statement?
a.Reflection
b.Facilitation
c.Direct question
d.Open-ended question - ✔️✔️Answer: D
The open-ended question asks for narrative information. It states the topic to be
discussed but only in general terms. The nurse should use it to begin the interview, to
introduce a new section of questions, and whenever the person introduces a new topic.
The nurse is conducting an interview with a woman who has recently learned that she is
pregnant and who has come to the clinic today to begin prenatal care. The woman
states that she and her husband are excited about the pregnancy but have a few
questions. She looks nervously at her hands during the interview and sighs loudly.
Considering the concept of communication, which statement does the nurse know to be
most accurate? The woman is:
a.Excited about her pregnancy but nervous about the labor.
b.Exhibiting verbal and nonverbal behaviors that do not match.
c.Excited about her pregnancy, but her husband is not and this is upsetting to her.
d.Not excited about her pregnancy but believes the nurse will negatively respond to her
if she states this. - ✔️✔️ANS: B
Communication is all behaviors, conscious and unconscious, verbal and nonverbal. All
behaviors have meaning. Her behavior does not imply that she is nervous about labor,
upset by her husband, or worried about the nurse's response.
Receiving is a part of the communication process. Which receiver is most likely to
misinterpret a message sent by a health care professional?
a.Well-adjusted adolescent who came in for a sports physical
, b.Recovering alcoholic who came in for a basic physical examination
c.Man whose wife has just been diagnosed with lung cancer
d.Man with a hearing impairment who uses sign language to communicate and who has
an interpreter with him - ✔️✔️ANS: C
The receiver attaches meaning determined by his or her experiences, culture, self-
concept, and current physical and emotional states. The man whose wife has just been
diagnosed with lung cancer may be experiencing emotions that affect his receiving.
In an interview, the nurse may find it necessary to take notes to aid his or her memory
later. Which statement is true regarding note-taking?
a. Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
b. Note-taking allows the patient to continue at his or her own pace as the nurse records
what is said.
c. Note-taking allows the nurse to shift attention away from the patient, resulting in an
increased comfort level.
d.Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort. - ✔️✔️ANS: A
The use of history forms and note-taking may be unavoidable. However, the nurse must
be aware that note-taking during the interview has disadvantages. It breaks eye contact
too often and shifts the attention away from the patient, which diminishes his or her
sense of importance. Note-taking may also interrupt the patient's narrative flow, and it
impedes the observation of the patient's nonverbal behavior.
The nurse asks, "I would like to ask you some questions about your health and your
usual daily activities so that we can better plan your stay here." This question is found at
the __________ phase of the interview process.
a.Summary
b.Closing
c.Body
d.Opening or introduction - ✔️✔️ANS: D
When gathering a complete history, the nurse should give the reason for the interview
during the opening or introduction phase of the interview, not during or at the end of the
interview.
