Test Bank for Advanced Health Assessment and Differential
Diagnosis Essentials For Clinical Practice
1st Edition Myrick, Chapters 1 - 12
,Advanced Health Assessment and Differential Diagnosis Essentials for Clinical Practice 1st
Edition Myrick Test Bank
Table of Contents:
Chapter 1. Health History, The Patient Interview, And Motivational Interviewing
Chapter 2. Advanced Health Assessment of the Head, Neck, and Lymphatic System
Chapter 3. Advanced Health Assessment of the Nose, Mouth, and Throat
Chapter 4. Advanced Health Assessment of the Eyes and Ears
Chapter 5. Advanced Health Assessment of Skin, Hair, and Nails
Chapter 6. Advanced Health Assessment of the Cardiovascular System
Chapter 7 Advanced Health Assessment of the Respiratory System
Chapter 8 Advanced Health Assessment of the Abdomen, Rectum, and Anus
Chapter 9 Advanced Health Assessment of the Male Genitourinary System
Chapter 10 Advanced Assessment of the Female Reproductive System
Chapter 11 Advanced Health Assessment of the Neurological System
Chapter 12 Advanced Health Assessment of the Musculoskeletal System
,Advanced Health Assessment and Differential Diagnosis Essentials for Clinical Practice 1st
Edition Myrick Test Bank
Chapter 1: Health History, The Patient Interview, And Motivational Interviewing
MULTIPLE CHOICE
1. The nurse is preparing to conduct a health history. Which of these statements best describes
the purpose of a health history?
a To provide an opportunity for interaction between the patient and the nurse
.
b To provide a form for obtaining the patients biographic information
.
c To document the normal and abnormal findings of a physical assessment
.
d To provide a database of subjective information about the patients past and
. current health
ANSWER: D
The purpose of the health history is to collect subjective datawhat the person says about him or
herself. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 49
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. When the nurse is evaluating the reliability of a patients responses, which of these statements
would be correct? The patient:
a Has a history of drug abuse and therefore is not reliable.
.
b Provided consistent information and therefore is reliable.
.
c Smiled throughout interview and therefore is assumed reliable.
.
d Would not answer questions concerning stress and therefore is not reliable.
.
ANSWER: 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) REF: dm. 49
,MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black
stools for the last 24 hours. How would the nurse best document his reason for seeking care?
a J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
.
b J.M. came into the clinic complaining of having black stools for the past 24
. hours.
c J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it
. checked.
d J.M. is a 59-year-old man who states that he has been having black stools for
. the past 24 hours.
ANSWER: D
The reason for seeking care is a brief spontaneous statement in the persons 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 persons exact words.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the
nurses best response?
a Can you point to where it hurts?
.
b Well talk more about that later in the interview.
.
c What have you had to eat in the last 24 hours?
.
d Have you ever had any surgeries on your abdomen?
.
ANSWER: A
A final summary of any symptom the person has should include, along with seven other critical
characteristics, Location: specific. The person is asked to point to the location.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would
be the nurses appropriate response to the womans statement?
, a How does your family react to your pain?
.
b The pain must be terrible. You probably pinched a nerve.
.
c Ive had back pain myself, and it can be excruciating.
.
d How would you say the pain affects your ability to do your daily activities?
.
ANSWER: D
The symptom of pain is difficult to quantify because of individual interpretation. With pain,
adjectives should be avoided and the patient should be asked how the pain affects his or her daily
activities. The other responses are not appropriate.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
6. In recording the childhood illnesses of a patient who denies having had any, which note by the
nurse would be most accurate?
a Patient denies usual childhood illnesses.
.
b Patient states he was a very healthy child.
.
c Patient states his sister had measles, but he didnt.
.
d Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
.
ANSWER: D
Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat.
Avoid recording usual childhood illnesses because an illness common in the persons childhood
may be unusual today (e.g., measles).
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 51
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
7. 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 six times.
.
ANSWER: 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 (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) REF: dm. 51
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. A patient tells the nurse that he is allergic to penicillin. What would be the nurses best
response to this information?
a Are you allergic to any other drugs?
.
b How often have you received penicillin?
.
c Ill write your allergy on your chart so you wont receive any penicillin.
.
d Describe what happens to you when you take penicillin.
.
ANSWER: D
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). With a
drug, this symptom should not be a side effect but a true allergic reaction.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 52
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. The nurse is taking a family history. Important diseases or problems about which the patient
should be specifically asked include:
a Emphysema.
.
, b Head trauma.
.
c Mental illness.
.
d Fractured bones.
.
ANSWER: C
Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes,
obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis,
allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and
tuberculosis should be asked.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 53-54
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. The review of systems provides the nurse with:
a Physical findings related to each system.
.
b Information regarding health promotion practices.
.
c An opportunity to teach the patient medical terms.
.
d Information necessary for the nurse to diagnose the patients medical problem.
.
ANSWER: B
The purposes of the review of systems are to: (1) evaluate the past and current health state of
each body system, (2) double check facts in case any significant data were omitted in the present
illness section, and (3) evaluate health promotion practices.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 54
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
11. Which of these statements represents subjective data the nurse obtained from the patient
regarding the patients skin?
a Skin appears dry.
.
b No lesions are obvious.
.
, c Patient tdenies tany tcolor tchange.
.
d Lesion tis tnoted ton tthe tlateral taspect tof tthe tright tarm.
.
ANSWER: tC
The thistory tshould tbe tlimited tto tpatient tstatements tor tsubjective tdatafactors tthat tthe tperson
tsays twere tor twere tnot tpresent.
DIF: tCognitive t Level: t Understanding t(Comprehension) tREF: t dm. t54
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
12. The tnurse tis tobtaining ta thistory tfrom ta t30-year-old tmale tpatient tand tis tconcerned
tabout thealth tpromotion tactivities. tWhich tof tthese tquestions twould tbe tappropriate tto tuse tto
tassess thealth tpromotion tactivities tfor tthis tpatient?
a Do tyou tperform ttesticular tself-examinations?
.
b Have t you tever tnoticed tany tpain tin t your ttesticles?
.
c Have t you t had tany tproblems twith tpassing t urine?
.
d Do t you t have tany thistory tof tsexually ttransmitted tdiseases?
.
ANSWER: tA
Health tpromotion tfor ta tman twould tinclude tthe tperformance tof ttesticular tself-examinations. tThe
tother tquestions tare tasking tabout tpossible tdisease tor tillness tissues.
DIF: tCognitive t Level: t Understanding t(Comprehension) tREF: t dm. t56
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
13. Which tof tthese tresponses tmight tthe tnurse texpect tduring ta t functional tassessment t of ta
t patienttwhose tleg tis tin ta tcast?
a I tbroke tmy tright tleg tin ta tcar taccident t2 tweeks tago.
.
b The tpain tis tdecreasing, tbut t I tstill tneed tto ttake tacetaminophen.
.
c I tcheck tthe tcolor tof tmy ttoes tevery tevening tjust tlike tI twas ttaught.
.
, d Im table tto ttransfer t myself t from tthe twheelchair tto tthe tbed twithout thelp.
.
ANSWER: tD
Functional tassessment t measures ta tpersons tself-care tability tin t the tareas tof tgeneral t physical
t healthtor tabsence tof tillness. tThe tother tstatements tconcern thealth tor tillness tissues.
DIF: tCognitive t Level: t Applying t(Application) tREF: t dm. t56
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
14. In tresponse tto ta tquestion tabout tstress, ta t39-year-old twoman ttells tthe tnurse tthat t her
thusbandtand tmother tboth tdied tin tthe tpast tyear. tWhich tresponse tby tthe tnurse tis tmost
tappropriate?
a This thas tbeen ta tdifficult tyear tfor tyou.
.
b I tdont tknow thow tanyone tcould thandle tthat tmuch tstress tin t1 tyear!
.
c What tdid tyou tdo tto tcope twith tthe tloss tof tboth tyour thusband tand t mother?
.
d That tis ta tlot tof tstress; tnow tlets tgo ton tto tthe tnext tsection tof tyour thistory.
.
ANSWER: tC
Questions tabout t coping tand t stress t management t include t questions t regarding tthe t kinds tof
t stressestin tones tlife, tespecially tin tthe tlast t year, tany tchanges tin tlifestyle tor tany tcurrent tstress,
t methods ttried tto trelieve tstress, tand twhether tthese tmethods thave tbeen thelpful.
DIF: tCognitive t Level: t Applying t(Application) tREF: t dm. t57
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
15. In tresponse tto ta tquestion tregarding tthe tuse tof talcohol, ta tpatient tasks tthe tnurse twhy tthe
tnursetneeds tto tknow. tWhat tis tthe treason tfor tneeding tthis tinformation?
a This t information t is tnecessary tto tdetermine tthe t patients treliability.
.
b Alcohol tcan tinteract twith tall t medications t and tcan t make tsome tdiseases tworse.
.
c The tnurse tneeds tto tbe table tto tteach tthe tpatient tabout tthe tdangers tof talcohol tuse.
.
d This t information t is tnot t necessary tunless ta tdrinking t problem t is tobvious.
.
ANSWER: tB
, Alcohol tadversely tinteracts twith tall t medications tand tis ta tfactor tin t many tsocial tproblems tsuch
tastchild tor tsexual tabuse, tautomobile taccidents, tand tassaults; talcohol talso tcontributes tto tmany
tillnesses tand tdisease tprocesses. tTherefore, tassessing tfor tsigns tof thazardous talcohol t use tis
timportant. tThe tother toptions tare tnot tcorrect.
DIF: tCognitive t Level: t Understanding t(Comprehension) tREF: t dm. t58
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
16. The tmother tof ta t16-month-old ttoddler ttells tthe t nurse tthat ther tdaughter t has tan tearache.
tWhattwould tbe tan tappropriate tresponse?
a Maybe tshe tis tjust tteething.
.
b I twill tcheck ther tear tfor tan tear tinfection.
.
c Are tyou tsure tshe tis treally thaving tpain?
.
d Describe twhat tshe tis tdoing tto tindicate tshe tis thaving tpain.
.
ANSWER: tD
With ta tvery tyoung tchild, tthe tparent tis tasked, tHow tdo tyou tknow tthe tchild tis tin tpain? tA
tyoung tchild tpulling tat this tor ther tears tshould talert tparents tto tthe tchilds tear tpain. tStatements
tabout tteething tand tquestioning twhether tthe tchild tis treally thaving tpain tdo t not texplore tthe
tsymptoms,twhich tshould tbe tdone tbefore ta tphysical texamination.
17. During ta tvisit tto tthe tclinic, ta tpatient tstates, tThe tdoctor tjust ttold tme the tthought tI tought tto
tstoptsmoking. tHe tdoesnt tunderstand t how thard tIve ttried. tI tjust tdont tknow tthe tbest tway tto tdo
tit. tWhat tshould tI tdo? tThe tnurses tmost tappropriate tresponse tin tthis tcase twould tbe:
a Id tquit tif tI twere t you. tThe tdoctor treally tknows twhat the tis ttalking tabout.
.
b Would t you t like tsome tinformation tabout tthe tdifferent tways ta tperson tcan
. tquitts moking?
c Stopping tyour t dependence ton t cigarettes tcan tbe t very tdifficult. t I tunderstand
. t howtyou tfeel.
d Why tare t you tconfused? t Didnt tthe tdoctor tgive t you tthe t information tabout
. tthets moking tcessation tprogram twe toffer?
ANSWER: tB
Clarification tshould tbe tused twhen tthe tpersons tword tchoice tis tambiguous tor tconfusing.
tClarification tis talso tused tto tsummarize tthe tpersons twords tor tto tsimplify tthe twords tto tmake
tthemtclearer; tthe tnurse tshould tthen task tif the tor tshe tis ton tthe tright ttrack. tThe tother tresponses
tgive
Diagnosis Essentials For Clinical Practice
1st Edition Myrick, Chapters 1 - 12
,Advanced Health Assessment and Differential Diagnosis Essentials for Clinical Practice 1st
Edition Myrick Test Bank
Table of Contents:
Chapter 1. Health History, The Patient Interview, And Motivational Interviewing
Chapter 2. Advanced Health Assessment of the Head, Neck, and Lymphatic System
Chapter 3. Advanced Health Assessment of the Nose, Mouth, and Throat
Chapter 4. Advanced Health Assessment of the Eyes and Ears
Chapter 5. Advanced Health Assessment of Skin, Hair, and Nails
Chapter 6. Advanced Health Assessment of the Cardiovascular System
Chapter 7 Advanced Health Assessment of the Respiratory System
Chapter 8 Advanced Health Assessment of the Abdomen, Rectum, and Anus
Chapter 9 Advanced Health Assessment of the Male Genitourinary System
Chapter 10 Advanced Assessment of the Female Reproductive System
Chapter 11 Advanced Health Assessment of the Neurological System
Chapter 12 Advanced Health Assessment of the Musculoskeletal System
,Advanced Health Assessment and Differential Diagnosis Essentials for Clinical Practice 1st
Edition Myrick Test Bank
Chapter 1: Health History, The Patient Interview, And Motivational Interviewing
MULTIPLE CHOICE
1. The nurse is preparing to conduct a health history. Which of these statements best describes
the purpose of a health history?
a To provide an opportunity for interaction between the patient and the nurse
.
b To provide a form for obtaining the patients biographic information
.
c To document the normal and abnormal findings of a physical assessment
.
d To provide a database of subjective information about the patients past and
. current health
ANSWER: D
The purpose of the health history is to collect subjective datawhat the person says about him or
herself. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 49
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. When the nurse is evaluating the reliability of a patients responses, which of these statements
would be correct? The patient:
a Has a history of drug abuse and therefore is not reliable.
.
b Provided consistent information and therefore is reliable.
.
c Smiled throughout interview and therefore is assumed reliable.
.
d Would not answer questions concerning stress and therefore is not reliable.
.
ANSWER: 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) REF: dm. 49
,MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black
stools for the last 24 hours. How would the nurse best document his reason for seeking care?
a J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
.
b J.M. came into the clinic complaining of having black stools for the past 24
. hours.
c J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it
. checked.
d J.M. is a 59-year-old man who states that he has been having black stools for
. the past 24 hours.
ANSWER: D
The reason for seeking care is a brief spontaneous statement in the persons 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 persons exact words.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the
nurses best response?
a Can you point to where it hurts?
.
b Well talk more about that later in the interview.
.
c What have you had to eat in the last 24 hours?
.
d Have you ever had any surgeries on your abdomen?
.
ANSWER: A
A final summary of any symptom the person has should include, along with seven other critical
characteristics, Location: specific. The person is asked to point to the location.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would
be the nurses appropriate response to the womans statement?
, a How does your family react to your pain?
.
b The pain must be terrible. You probably pinched a nerve.
.
c Ive had back pain myself, and it can be excruciating.
.
d How would you say the pain affects your ability to do your daily activities?
.
ANSWER: D
The symptom of pain is difficult to quantify because of individual interpretation. With pain,
adjectives should be avoided and the patient should be asked how the pain affects his or her daily
activities. The other responses are not appropriate.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
6. In recording the childhood illnesses of a patient who denies having had any, which note by the
nurse would be most accurate?
a Patient denies usual childhood illnesses.
.
b Patient states he was a very healthy child.
.
c Patient states his sister had measles, but he didnt.
.
d Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
.
ANSWER: D
Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat.
Avoid recording usual childhood illnesses because an illness common in the persons childhood
may be unusual today (e.g., measles).
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 51
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
7. 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 six times.
.
ANSWER: 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 (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) REF: dm. 51
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. A patient tells the nurse that he is allergic to penicillin. What would be the nurses best
response to this information?
a Are you allergic to any other drugs?
.
b How often have you received penicillin?
.
c Ill write your allergy on your chart so you wont receive any penicillin.
.
d Describe what happens to you when you take penicillin.
.
ANSWER: D
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). With a
drug, this symptom should not be a side effect but a true allergic reaction.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 52
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. The nurse is taking a family history. Important diseases or problems about which the patient
should be specifically asked include:
a Emphysema.
.
, b Head trauma.
.
c Mental illness.
.
d Fractured bones.
.
ANSWER: C
Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes,
obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis,
allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and
tuberculosis should be asked.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 53-54
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. The review of systems provides the nurse with:
a Physical findings related to each system.
.
b Information regarding health promotion practices.
.
c An opportunity to teach the patient medical terms.
.
d Information necessary for the nurse to diagnose the patients medical problem.
.
ANSWER: B
The purposes of the review of systems are to: (1) evaluate the past and current health state of
each body system, (2) double check facts in case any significant data were omitted in the present
illness section, and (3) evaluate health promotion practices.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 54
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
11. Which of these statements represents subjective data the nurse obtained from the patient
regarding the patients skin?
a Skin appears dry.
.
b No lesions are obvious.
.
, c Patient tdenies tany tcolor tchange.
.
d Lesion tis tnoted ton tthe tlateral taspect tof tthe tright tarm.
.
ANSWER: tC
The thistory tshould tbe tlimited tto tpatient tstatements tor tsubjective tdatafactors tthat tthe tperson
tsays twere tor twere tnot tpresent.
DIF: tCognitive t Level: t Understanding t(Comprehension) tREF: t dm. t54
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
12. The tnurse tis tobtaining ta thistory tfrom ta t30-year-old tmale tpatient tand tis tconcerned
tabout thealth tpromotion tactivities. tWhich tof tthese tquestions twould tbe tappropriate tto tuse tto
tassess thealth tpromotion tactivities tfor tthis tpatient?
a Do tyou tperform ttesticular tself-examinations?
.
b Have t you tever tnoticed tany tpain tin t your ttesticles?
.
c Have t you t had tany tproblems twith tpassing t urine?
.
d Do t you t have tany thistory tof tsexually ttransmitted tdiseases?
.
ANSWER: tA
Health tpromotion tfor ta tman twould tinclude tthe tperformance tof ttesticular tself-examinations. tThe
tother tquestions tare tasking tabout tpossible tdisease tor tillness tissues.
DIF: tCognitive t Level: t Understanding t(Comprehension) tREF: t dm. t56
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
13. Which tof tthese tresponses tmight tthe tnurse texpect tduring ta t functional tassessment t of ta
t patienttwhose tleg tis tin ta tcast?
a I tbroke tmy tright tleg tin ta tcar taccident t2 tweeks tago.
.
b The tpain tis tdecreasing, tbut t I tstill tneed tto ttake tacetaminophen.
.
c I tcheck tthe tcolor tof tmy ttoes tevery tevening tjust tlike tI twas ttaught.
.
, d Im table tto ttransfer t myself t from tthe twheelchair tto tthe tbed twithout thelp.
.
ANSWER: tD
Functional tassessment t measures ta tpersons tself-care tability tin t the tareas tof tgeneral t physical
t healthtor tabsence tof tillness. tThe tother tstatements tconcern thealth tor tillness tissues.
DIF: tCognitive t Level: t Applying t(Application) tREF: t dm. t56
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
14. In tresponse tto ta tquestion tabout tstress, ta t39-year-old twoman ttells tthe tnurse tthat t her
thusbandtand tmother tboth tdied tin tthe tpast tyear. tWhich tresponse tby tthe tnurse tis tmost
tappropriate?
a This thas tbeen ta tdifficult tyear tfor tyou.
.
b I tdont tknow thow tanyone tcould thandle tthat tmuch tstress tin t1 tyear!
.
c What tdid tyou tdo tto tcope twith tthe tloss tof tboth tyour thusband tand t mother?
.
d That tis ta tlot tof tstress; tnow tlets tgo ton tto tthe tnext tsection tof tyour thistory.
.
ANSWER: tC
Questions tabout t coping tand t stress t management t include t questions t regarding tthe t kinds tof
t stressestin tones tlife, tespecially tin tthe tlast t year, tany tchanges tin tlifestyle tor tany tcurrent tstress,
t methods ttried tto trelieve tstress, tand twhether tthese tmethods thave tbeen thelpful.
DIF: tCognitive t Level: t Applying t(Application) tREF: t dm. t57
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
15. In tresponse tto ta tquestion tregarding tthe tuse tof talcohol, ta tpatient tasks tthe tnurse twhy tthe
tnursetneeds tto tknow. tWhat tis tthe treason tfor tneeding tthis tinformation?
a This t information t is tnecessary tto tdetermine tthe t patients treliability.
.
b Alcohol tcan tinteract twith tall t medications t and tcan t make tsome tdiseases tworse.
.
c The tnurse tneeds tto tbe table tto tteach tthe tpatient tabout tthe tdangers tof talcohol tuse.
.
d This t information t is tnot t necessary tunless ta tdrinking t problem t is tobvious.
.
ANSWER: tB
, Alcohol tadversely tinteracts twith tall t medications tand tis ta tfactor tin t many tsocial tproblems tsuch
tastchild tor tsexual tabuse, tautomobile taccidents, tand tassaults; talcohol talso tcontributes tto tmany
tillnesses tand tdisease tprocesses. tTherefore, tassessing tfor tsigns tof thazardous talcohol t use tis
timportant. tThe tother toptions tare tnot tcorrect.
DIF: tCognitive t Level: t Understanding t(Comprehension) tREF: t dm. t58
MSC: tClient tNeeds: tSafe tand tEffective tCare tEnvironment: tManagement tof tCare
16. The tmother tof ta t16-month-old ttoddler ttells tthe t nurse tthat ther tdaughter t has tan tearache.
tWhattwould tbe tan tappropriate tresponse?
a Maybe tshe tis tjust tteething.
.
b I twill tcheck ther tear tfor tan tear tinfection.
.
c Are tyou tsure tshe tis treally thaving tpain?
.
d Describe twhat tshe tis tdoing tto tindicate tshe tis thaving tpain.
.
ANSWER: tD
With ta tvery tyoung tchild, tthe tparent tis tasked, tHow tdo tyou tknow tthe tchild tis tin tpain? tA
tyoung tchild tpulling tat this tor ther tears tshould talert tparents tto tthe tchilds tear tpain. tStatements
tabout tteething tand tquestioning twhether tthe tchild tis treally thaving tpain tdo t not texplore tthe
tsymptoms,twhich tshould tbe tdone tbefore ta tphysical texamination.
17. During ta tvisit tto tthe tclinic, ta tpatient tstates, tThe tdoctor tjust ttold tme the tthought tI tought tto
tstoptsmoking. tHe tdoesnt tunderstand t how thard tIve ttried. tI tjust tdont tknow tthe tbest tway tto tdo
tit. tWhat tshould tI tdo? tThe tnurses tmost tappropriate tresponse tin tthis tcase twould tbe:
a Id tquit tif tI twere t you. tThe tdoctor treally tknows twhat the tis ttalking tabout.
.
b Would t you t like tsome tinformation tabout tthe tdifferent tways ta tperson tcan
. tquitts moking?
c Stopping tyour t dependence ton t cigarettes tcan tbe t very tdifficult. t I tunderstand
. t howtyou tfeel.
d Why tare t you tconfused? t Didnt tthe tdoctor tgive t you tthe t information tabout
. tthets moking tcessation tprogram twe toffer?
ANSWER: tB
Clarification tshould tbe tused twhen tthe tpersons tword tchoice tis tambiguous tor tconfusing.
tClarification tis talso tused tto tsummarize tthe tpersons twords tor tto tsimplify tthe twords tto tmake
tthemtclearer; tthe tnurse tshould tthen task tif the tor tshe tis ton tthe tright ttrack. tThe tother tresponses
tgive
