Test Bank Evidence-Based Physical Examination Best Practices for Health & Well-Being Assessment 1st Edition Gawlik

Test Bank Evidence-Based Physical Examination Best Practices for Health & Well-Being Assessment 1st Edition Gawlik Table of Contents Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELLBEING ......................................................................................................................................... 3 Chapter 2. EVIDENCE-BASED HISTORY-TAKING APPROACH FOR WELLNESS EXAMS, EPISODIC VISITS, AND CHRONIC CARE MANAGEMENT ..................................................... 18 Chapter 3. APPROACH TO IMPLEMENTING AND DOCUMENTING PATIENT- CENTERED, CULTURALLY SENSITIVE EVIDENCE-BASED ASSESSMENT .............................................. 35 Chapter 4. EVIDENCE-BASED ASSESSMENT OF CHILDREN AND ADOLESCENTS ............ 53 Chapter 5. APPROACH TO THE PHYSICAL EXAMINATION: GENERAL SURVEY AND ASSESSMENT OF VITAL SIGNS ............................................................................................. 68 Chapter 6. EVIDENCE-BASED ASSESSMENT OF THE HEART AND CIRCULATORY SYSTEM .................................................................................................................................................. 93 Chapter 7. EVIDENCE-BASED ASSESSMENT OF THE LUNGS AND RESPIRATORY SYSTEM ................................................................................................................................................ 114 Chapter 8. APPROACH TO EVIDENCE-BASED ASSESSMENT OF BODY HABITUS (HEIGHT, WEIGHT, BODY MASS INDEX, NUTRITION) ......................................................................... 135 Chapter 9. EVIDENCE-BASED ASSESSMENT OF SKIN, HAIR, AND NAILS ........................ 152 Chapter 10. EVIDENCE-BASED ASSESSMENT OF THE LYMPHATIC SYSTEM .................. 176 Chapter 11. EVIDENCE-BASED ASSESSMENT OF THE HEAD AND NECK ........................ 200 Chapter 12. EVIDENCE-BASED ASSESSMENT OF THE EYE .............................................. 221 Chapter 13. EVIDENCE-BASED ASSESSMENT OF THE EARS, NOSE, AND THROAT ....... 241 Chapter 14. EVIDENCE-BASED ASSESSMENT OF THE NERVOUS SYSTEM .................... 262 Chapter 15. EVIDENCE-BASED ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM ... 289 Chapter 16. EVIDENCE-BASED ASSESSMENT OF THE ABDOMINAL, GASTROINTESTINAL, AND UROLOGICAL SYSTEMS .............................................................................................. 317 Chapter 17. EVIDENCE-BASED ASSESSMENT OF THE BREASTS AND AXILLAE ............. 335 Chapter 18. EVIDENCE-BASED ASSESSMENT OF SEXUAL ORIENTATION, GENDER IDENTITY, AND HEALTH ....................................................................................................... 360 Chapter 19. EVIDENCE-BASED ASSESSMENT OF MALE GENITALIA, PROSTATE, RECTUM, AND ANUS ............................................................................................................................. 377 Chapter 20. EVIDENCE-BASED ASSESSMENT OF THE FEMALE GENITOURINARY SYSTEM ................................................................................................................................................ 397 Chapter 21. EVIDENCE-BASED OBSTETRIC ASSESSMENT ............................................... 424 Chapter 22. EVIDENCE-BASED ASSESSMENT OF MENTAL HEALTH ................................ 440 Chapter 23. EVIDENCE-BASED ASSESSMENT OF SUBSTANCE USE DISORDER ............ 457 Chapter 24. EVIDENCE-BASED ASSESSMENT AND SCREENING FOR TRAUMATIC EXPERIENCES: ABUSE, NEGLECT, AND INTIMATE PARTNER VIOLENCE ....................... 463 Chapter 25. EVIDENCE-BASED THERAPEUTIC COMMUNICATION AND MOTIVATIONAL 1 | P a g eINTERVIEWING IN HEALTH ASSESSMENT ......................................................................... 470 Chapter 26. EVIDENCE-BASED HISTORY AND PHYSICAL EXAMINATIONS FOR SPORTS PARTICIPATION EVALUATION ............................................................................................. 495 Chapter 27. USING HEALTH TECHNOLOGY IN EVIDENCE-BASED ASSESSMENT ........... 515 Chapter 28. EVIDENCE-BASED ASSESSMENT OF PERSONAL HEALTH AND WELL- BEING FOR CLINICIANS: KEY STRATEGIES TO ACHIEVE OPTIMAL WELLNESS ........................ 531 Chapter 29. EVIDENCE-BASED HEALTH AND WELL-BEING ASSESSMENT: PUTTING IT ALL TOGETHER ............................................................................................................................ 551 2 | P a g eChapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL- BEING MULTIPLE CHOICE 1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a . b . c . d . Objective. Reflective. Subjective. Introspective. ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a . b . c . d . Objective. Reflective. Subjective. Introspective. ANS: C Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2 3 | P a g eMSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. The patients record, laboratory studies, objective data, and subjective data combine to form the: a . b . c . d . Data base. Admitting data. Financial statement. Discharge summary. ANS: A Together with the patients record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patients record, laboratory studies, or data. DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: a . b . c . d . Immediately notify the patients physician. Document the sound exactly as it was heard. Validate the data by asking a coworker to listen to the breath sounds. Assess again in 20 minutes to note whether the sound is still present. ANS: C When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen. DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: 4 | P a g ea . b . c . d . Intuition. A set of rules. Articles in journals. Advice from supervisors. ANS: B Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3 MSC: Client Needs: General 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a . b . c . d . Intuition. The nursing process. Clinical knowledge. Diagnostic reasoning. ANS: A Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4 MSC: Client Needs: General 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a . b . EBP relies on tradition for support of best practices. EBP is simply the use of best practice techniques for the treatment of patients. 5 | P a g ec . d . EBP emphasizes the use of best evidence with the clinicians experience. The patients own preferences are not important with EBP. ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, 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. DIF: Cognitive Level: Applying (Application) REF: z. 5 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a . b . c . d . Patient with postoperative pain Newly diagnosed patient with diabetes who needs diabetic teaching Individual with a small laceration on the sole of the foot Individual with shortness of breath and respiratory distress ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1). DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. When considering priority setting of problems, the nurse keeps in mind that second- level priority problems include which of these aspects? 6 | P a g ea . b . c . d . Low self-esteem Lack of knowledge Abnormal laboratory values Severely abnormal vital signs ANS: C Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1). DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. Which critical thinking skill helps the nurse see relationships among the data? a . b . c . d . Validation Clustering related cues Identifying gaps in data Distinguishing relevant from irrelevant ANS: B Clustering related cues helps the nurse see relationships among the data. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. a . Nursing b Medical . 7 | P a g ec . d . Admission Collaborative ANS: A An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a . b . c . d . Assessment, treatment, planning, evaluation, discharge, and follow-up Admission, assessment, diagnosis, treatment, and discharge planning Admission, diagnosis, treatment, evaluation, and discharge planning Assessment, diagnosis, outcome identification, planning, implementation, and evaluation ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a . b . c . Breathing, pain, and sleep Breathing, sleep, and pain Sleep, breathing, and pain 8 | P a g ed . Sleep, pain, and breathing ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems. DIF: Cognitive Level: Analyzing (Analysis) REF: z. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. Which of these would be formulated by a nurse using diagnostic reasoning? a . b . c . d . Nursing diagnosis Medical diagnosis Diagnostic hypothesis Diagnostic assessment ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2 MSC: Client Needs: General 15. Barriers to incorporating EBP include: a . b . c . d . Nurses lack of research skills in evaluating the quality of research studies. Lack of significant research studies. Insufficient clinical skills of nurses. Inadequate physical assessment skills. ANS: A As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered 9 | P a g ebarriers. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 6 MSC: Client Needs: General 16. What step of the nursing process includes data collection by health history, physical examination, and interview? a . b . c . d . Planning Diagnosis Evaluation Assessment ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2). DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2 MSC: Client Needs: General 17. 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 . b . c . d . Form a committee to conduct research studies. Post published research studies on the units bulletin boards. Encourage the nurses to visit the library to review studies. Teach the nurses how to conduct electronic searches for research studies. ANS: D Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library 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. DIF: Cognitive Level: Applying (Application) REF: z. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10 | P a g e18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a . b . c . d . Disease originates from the external environment. The individual human is a closed system. Nurses are responsible for a patients health state. Holistic health views the mind, body, and spirit as interdependent. ANS: D Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. The nurse recognizes that the concept of prevention in describing health is essential because: a . b . c . d . Disease can be prevented by treating the external environment. The majority of deaths among Americans under age 65 years are not preventable. Prevention places the emphasis on the link between health and personal behavior. The means to prevention is through treatment provided by primary health care practitioners. ANS: C A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 7 MSC: Client Needs: General 20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: 11 | P a g ea . b . c . d . Patients history of allergies. Patients use of medications at home. Last menstrual period 1 month ago. 2 5 cm scar on the right lower forearm. ANS: D Objective data are the patients 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. DIF: Cognitive Level: Applying (Application) REF: z. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a . b . c . d . A follow-up data base to evaluate changes at appropriate intervals An episodic data base because of the continuing, complex medical problems of this patient A complete health data base because of the nurses primary responsibility for monitoring the patients health An emergency data base because of the need to collect information and make accurate diagnoses rapidly ANS: C The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womens 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 persons health care. DIF: Cognitive Level: Applying (Application) REF: z. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 22. Which situation is most appropriate during which the nurse performs a focused or problem- centered history? 12 | P a g ea . b . c . d . Patient is admitted to a long-term care facility. Patient has a sudden and severe shortness of breath. Patient is admitted to the hospital for surgery the following day. Patient in an outpatient clinic has cold and influenza-like symptoms. ANS: D In a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope than the completed data base. This mini data base primarily concerns one problem, one cue complex, or one body system. DIF: Cognitive Level: Applying (Application) REF: z. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 23. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a . b . c . d . Collect a follow-up data base and then check her blood pressure. Ask her to read her health record and indicate any changes since her last visit. Check only her blood pressure because her complete health history was documented 2 months ago. Obtain a complete health history before checking her blood pressure because much of her history information may have changed. ANS: A A follow-up data base is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation. DIF: Cognitive Level: Applying (Application) REF: z. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 24. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a . Collect history information first, then perform the physical examination and institute life-saving measures. 13 | P a g eb . c . d . Simultaneously ask history questions while performing the examination and initiating life-saving measures. Collect all information on the history form, including social support patterns, strengths, and coping patterns. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit. ANS: B The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation. DIF: Cognitive Level: Analyzing (Analysis) REF: z. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a . b . c . d . Identify the cause of his illness. Make accurate disease diagnoses. Provide cultural health rights for the individual. Provide culturally sensitive and appropriate care. ANS: D The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 8 MSC: Client Needs: Psychosocial Integrity 26. In the health promotion model, the focus of the health professional includes: a . b . 14 | P a g e Changing the patients perceptions of disease. Identifying biomedical model interventions.c . Identifying negative health acts of the consumer. 15 | P a g ed . Helping the consumer choose a healthier lifestyle. ANS: D In the health promotion model, the focus of the health professional is on helping the consumer choose a healthier lifestyle. DIF: Cognitive Level: Remembering (Knowledge) REF: z. 8 MSC: Client Needs: Health Promotion and Maintenance 27. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a . b . c . d . Establish priorities. Identify expected outcomes. Evaluate the individuals condition, and compare actual outcomes with expected outcomes. Interpret data, and then identify clusters of cues and make inferences. ANS: C Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse evaluates the individuals condition and compares the actual outcomes with expected outcomes (See Figure 1-2). DIF: Cognitive Level: Applying (Application) REF: z. 3 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 28. Which statement best describes a proficient nurse? A proficient nurse is one who: a . b . c . d . Has little experience with a specified population and uses rules to guide performance. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. Sees actions in the context of daily plans for patients. 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 16 | P a g ea patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see how todays nursing actions can apply to the point the nurse wants the patient to reach at a future time. DIF: Cognitive Level: Applying (Application) REF: z. 3 MSC: Client Needs: General MULTIPLE RESPONSE 1. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. a . b . c . d . e . f . Inspiratory wheezes noted in left lower lobes Hypoactive bowel sounds Nonproductive cough Edema, +2, noted on left hand Patient reports dyspnea upon exertion Rate of respirations 16 breaths per minute ANS: A, C, E, F Clustering related cues help the nurse recognize relationships among the data. The cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are not related to the respiratory cues. DIF: Cognitive Level: Analyzing (Analysis) REF: z. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care MATCHING Put the following patient situations in order according to the level of priority. a . b . c . A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. A teenager who was stung by a bee during a soccer match is having trouble breathing. An older adult with a urinary tract infection is also showing signs of confusion and agitation. 2. b = Second-level priority problem 17 | P a g e3. c = Third-level priority problem 1. ANS: B DIF: Cognitive Level: Analyzing (Analysis) REF: z. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the airway, breathing, circulation priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e.g., patient education) are important to a patients health but can be addressed after more urgent health problems are addressed (see Table 1-1). 2. ANS: C DIF: Cognitive Level: Analyzing (Analysis) REF: z. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the airway, breathing, circulation priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e.g., patient education) are important to a patients health but can be addressed after more urgent health problems are addressed Chapter 2. EVIDENCE-BASED HISTORY-TAKING APPROACH FOR WELLNESS EXAMS, EPISODIC VISITS, AND CHRONIC CARE MANAGEMENT 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 . b . c . d . To provide an opportunity for interaction between the patient and the nurse To provide a form for obtaining the patients biographic information To document the normal and abnormal findings of a physical assessment To provide a database of subjective information about the patients past and current health ANS: 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: z. 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 . 18 | P a g e Has a history of drug abuse and therefore is not reliable.b . c . d . Provided consistent information and therefore is reliable. Smiled throughout interview and therefore is assumed reliable. 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) REF: z. 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 . b . c . d . J.M. is a 59-year-old man seeking treatment for ulcerative colitis. J.M. came into the clinic complaining of having black stools for the past 24 hours. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours. ANS: 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: z. 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 . b . Can you point to where it hurts? Well talk more about that later in the interview. 19 | P a g ec . d . What have you had to eat in the last 24 hours? Have you ever had any surgeries on your abdomen? ANS: 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: z. 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 . b . c . d . How does your family react to your pain? The pain must be terrible. You probably pinched a nerve. Ive had back pain myself, and it can be excruciating. 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. 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: z. 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 . b . c . Patient denies usual childhood illnesses. Patient states he was a very healthy child. Patient states his sister had measles, but he didnt. 20 | P a g ed throat. . ANS: 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: z. 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 . b . c . d . P-6, B-4, (S)Ab-2 Grav 6, Term 4, (S)Ab-2, Living 4 Patient has had four living babies. Patient has been pregnant six 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 (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: z. 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 . b . Are you allergic to any other drugs? How often have you received penicillin? Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep 21 | P a g ec . d . Ill write your allergy on your chart so you wont receive any Describe what happens to you when you take penicillin. ANS: 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: z. 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 . b . c . d . Emphysema. Head trauma. Mental illness. Fractured bones. ANS: 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: z 53-54 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. The review of systems provides the nurse with: a . b . c . 22 | P a g e Physical findings related to each system. Information regarding health promotion practices. An opportunity to teach the patient medical terms. penicillin.d . Information necessary for the nurse to diagnose the patients medical problem. ANS: 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: z. 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 . b . c . d . Skin appears dry. No lesions are obvious. Patient denies any color change. Lesion is noted on the lateral aspect of the right arm. ANS: C The history should be limited to patient statements or subjective datafactors that the person says were or were not present. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 54 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a . b . c . d . Do you perform testicular self-examinations? Have you ever noticed any pain in your testicles? Have you had any problems with passing urine? Do you have any history of sexually transmitted diseases? ANS: A Health promotion for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues. 23 | P a g eDIF: Cognitive Level: Understanding (Comprehension) REF: z. 56 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a . b . c . d . I broke my right leg in a car accident 2 weeks ago. The pain is decreasing, but I still need to take acetaminophen. I check the color of my toes every evening just like I was taught. Im able to transfer myself from the wheelchair to the bed without help. ANS: D Functional assessment measures a persons self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues. DIF: Cognitive Level: Applying (Application) REF: z. 56 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. 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 . b . c . d . This has been a difficult year for you. I dont know how anyone could handle that much stress in 1 year! What did you do to cope with the loss of both your husband and mother? That is a lot of stress; now lets 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 ones 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) REF: z. 57 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? 24 | P a g ea . b . c . d . This information is necessary to determine the patients reliability. Alcohol can interact with all medications and can make some diseases worse. The nurse needs to be able to teach the patient about the dangers of alcohol use. This information is not necessary unless a drinking problem is obvious. ANS: B Alcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 58 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a . b . c . d . Maybe she is just teething. I will check her ear for an ear infection. Are you sure she is really having pain? 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 childs 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) REF: z. 59 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 17. During an assessment of a patients family history, the nurse constructs a genogram. Which statement best describes a genogram? a . 25 | P a g e List of diseases present in a persons near relativesb . c . d . Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members Drawing that depicts the patients family members up to five generations back Description of the health of a persons children and grandchildren ANS: B A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). The other options do not describe a genogram. DIF: Cognitive Level: Applying (Application) REF: z 52-53 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. 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 . b . c . d . Childs birth weight Age at which he crawled Whether the child has had the measles Childs 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. DIF: Cognitive Level: Analyzing (Analysis) REF: z. 64 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. 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 recommendation should the nurse make? a . 26 | P a g e No further MMR immunizations are needed.b . c . d . MMR vaccination needs to be repeated at 4 to 6 years of age. MMR immunization needs to be repeated every 4 years until age 21 years. 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 (2006) 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: Analyzing (Analysis) REF: z. 60 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 20. In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the: a . b . c . d . Last glaucoma examination. Frequency of breast self-examinations. Date of her last electrocardiogram. Limitations related to her involvement in sports activities. ANS: D When reviewing the cardiovascular system, the health care provider should ask whether 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. DIF: Cognitive Level: Applying (Application) REF: z. 62 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? 27 | P a g ea . b . c . d . Family history Review of systems Functional assessment Reason for seeking care ANS: C Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 63 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 22. The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a . b . c . d . Obstetric history Childhood illnesses General health for the past 20 years Current health promotion activities ANS: D It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age. DIF: Cognitive Level: Applying (Application) REF: z. 54 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 23. The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a . 28 | P a g e The questions asked are identical for all ages.b . c . d . The interviewer will start incorporating different questions for patients 70 years of age and older. Questions that are reflective of the normal effects of aging are added. At this age, a review of systems is not necessarythe focus should be on current problems. ANS: C The health history includes the same format as that described for the younger adult, as well as some additional questions. These additional questions address ways in which the activities of daily living may have been affected by the normal aging processes or by the effects of chronic illness or disability. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 54 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 24. A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a . b . c . d . Can you tell me what they look like? Dont worry about it. You are only taking two medications. How long have you been taking each of the pills? Would you have a family member bring in your medications? ANS: D The person may not know the drug name or purpose. When this occurs, ask the person or a family member to bring in the drug to be identified. The other responses would not help to identify the medications. DIF: Cognitive Level: Applying (Application) REF: z. 52 MSC: Client Needs: Safe and Effective Care Environment: Management of Care