Complete Solutions
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6
months since you've been in, but your appointment was for every 2 months. Tell me about that.
Also I see from your last visit that the doctor recommended routine exercise. Can you tell me
how successful you have been following his plan?" The nurse's assessment covers which of
Gordon's functional health patterns?
A) Value-belief pattern
B) Cognitive-perceptual pattern
C) Coping-stress-tolerance pattern
D) Health perception-health management pattern - ANS Health perception-health
management pattern
The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do
you prefer? Have you noticed a change in your weight recently?" This series of questions would
likely occur during which phase of a patient-centered interview?
A) Setting the stage
B) Gathering information about the patient's chief concerns
C) Collecting the assessment
D) Termination - ANS Collecting the assessment
What type of interview techniques does the nurse use when asking these questions, "Do you
have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.)
A) Active listening
B) Open-ended questioning
C) Closed-ended questioning
D) Problem-oriented questioning - ANS Closed-ended questioning
Problem-oriented questioning
What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.)
A) Active listening
B) Back channeling
C) Validating
D) Use of open-ended questions
E) Use of closed-ended questions - ANS Active listening
Back channeling
Use of open-ended questions
, A nurse gathers the following assessment data. Which of the following cues form(s) a pattern
suggesting a problem? (Select all that apply.)
A) The skin around the wound is tender to touch.
B) Fluid intake for 8 hours is 800 mL.
C) Patient has a heart rate of 78 and regular.
D) Patient has drainage from surgical wound.
E) Body temperature is 101° F (38.3° C).
F) Patient asks, "I'm worried that I won't return to work when I planned." - ANS The skin
around the wound is tender to touch.
Patient has drainage from surgical wound.
Body temperature is 101° F (38.3° C).
The nurse makes the following statement during a change of shift report to another nurse. "I
assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days
ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his
leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often
have chronic pain. He seems fine when talking with his family. Have you cared for him before?"
What does the nurse's conclusion suggest?
A) The nurse is making an accurate clinical inference.
B) The nurse has gathered cues to identify a potential problem area.
C) The nurse has allowed stereotyping to influence her assessment.
D) The nurse wants to validate her information with the other nurse. - ANS The nurse has
allowed stereotyping to influence her assessment.
A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where
the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just
above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line
is running at the correct rate. This is an example of what type of assessment?
A) Agenda setting
B) Problem-focused
C) Objective
D) Use of a structured database format - ANS Problem-focused
A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from
shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain
how he uses the inhaler, when he should take a dose of medication, and what he does when he
gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse
assess?
A) Health perception-health management pattern
B) Value-belief pattern
C) Cognitive-perceptual pattern
D) Coping-stress tolerance pattern - ANS Health perception-health management pattern