Jarvis Physical Examination & Health Assessment 7th Edition – Test Bank with Complete Solutions

Jarvis Physical Examination & Health Assessment 7th Edition – Test Bank with Complete SolutionsPhysical Examination and Health Assessment 7th Edition with Complete Solutions Table of Contents Chapter 01: Evidence-Based Assessment Chapter 02: Cultural Competence Chapter 03: The Interview Chapter 04: The Complete Health History Chapter 05: Mental Status Assessment Chapter 06: Substance Use Assessment Chapter 07: Domestic and Family Violence Assessments Chapter 08: Assessment Techniques and Safety in the Clinical Setting Chapter 09: General Survey, Measurement, Vital Signs Chapter 10: Pain Assessment: The Fifth Vital Sign Chapter 11: Nutritional Assessment Chapter 12: Skin, Hair, and Nails Chapter 13: Head, Face, and Neck, Including Regional Lymphatics Chapter 14: Eyes Chapter 15: Ears Chapter 16: Nose, Mouth, and Throat Chapter 17: Breasts and Regional Lymphatics Chapter 18: Thorax and Lungs Chapter 19: Heart and Neck Vessels Chapter 20: Peripheral Vascular System and Lymphatic System Chapter 21: Abdomen Chapter 22: Musculoskeletal System Chapter 23: Neurologic System Chapter 24: Male Genitourinary System Chapter 25: Anus, Rectum, and Prostate Chapter 26: Female Genitourinary System Chapter 27: The Complete Health Assessment: Adult Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent Chapter 29: Bedside Assessment of the Hospitalized Patient Chapter 30: The Pregnant Woman Chapter 31: Functional Assessment of the Older Adult Chapter 01: Evidence-Based Assessment Chapter 01: Evidence-Based Assessment Jarvis: Physical Examination & Health Assessment, 7th Edition 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. Objective. b. Reflective. c. Subjective. d. 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: p. 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. Objective. b. Reflective. c. Subjective. d. 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: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary. ANS: A Together with the patient’s record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patient’s record, laboratory studies, or data. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to: a. Immediately notify the patient’s physician. b. Document the sound exactly as it was heard. c. Validate the data by asking a coworker to listen to the breath sounds. d. 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 patient’s 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: p. 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: a. Intuition. b. A set of rules. c. Articles in journals. d. 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: p. 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. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning. ANS: A Intuition is characterized by pattern recognition—expert 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: p. 4 MSC: Client Needs: General 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinician’s experience. d. The patient’s 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 clinician’s 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: p. 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. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. 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: p. 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? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. 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: p. 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. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant ANS: B Clustering related cues helps the nurse see relationships among the data. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 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 c. Admission d. 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: p. 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. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. 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: p. 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. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. 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: p. 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. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. 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: p. 2 MSC: Client Needs: General 15. Barriers to incorporating EBP include: a. Nurses’ lack of research skills in evaluating the quality of research studies. b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. 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 barriers. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: General 16. What step of the nursing process includes data collection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. 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). 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. Form a committee to conduct research studies. b. Post published research studies on the unit’s bulletin boards. c. Encourage the nurses to visit the library to review studies. d. 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: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Disease originates from the external environment. b. The individual human is a closed system. c. Nurses are responsible for a patient’s health state. d. 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: p. 7 19. The nurse recognizes that the concept of prevention in describing health is essential because: a. Disease can be prevented by treating the external environment. b. The majority of deaths among Americans under age 65 years are not preventable. c. Prevention places the emphasis on the link between health and personal behavior. d. 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: p. 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: a. Patient’s history of allergies. b. Patient’s use of medications at home. c. Last menstrual period 1 month ago. d. 2  5 cm scar on the right lower forearm. ANS: D Objective data are the patient’s 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: p. 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. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient A complete health data base because of the nurse’s primary responsibility for monitoring c. the patient’s health An emergency data base because of the need to collect information and make accurate d. 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, women’s 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 person’s health care. DIF: Cognitive Level: Applying (Application) REF: p. 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? a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. 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: p. 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. Collect a follow-up data base and then check her blood pressure. b. 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 c. months ago. Obtain a complete health history before checking her blood pressure because much of her d. 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: p. 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? Collect history information first, then perform the physical examination and institute life- a. saving measures. Simultaneously ask history questions while performing the examination and initiating life- b. saving measures. Collect all information on the history form, including social support patterns, strengths, and c. coping patterns. Perform life-saving measures and delay asking any history questions until the patient is d. 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: p. 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. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for the individual. d. 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: p. 8 MSC: Client Needs: Psychosocial Integrity 26. In the health promotion model, the focus of the health professional includes: a. Changing the patient’s perceptions of disease. b. Identifying biomedical model interventions. c. Identifying negative health acts of the consumer. d. 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: p. 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. Establish priorities. b. Identify expected outcomes. c. Evaluate the individual’s condition, and compare actual outcomes with expected outcomes. d. 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 individual’s condition and compares the actual outcomes with expected outcomes (See Figure 1-2). DIF: Cognitive Level: Applying (Application) REF: p. 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. Has little experience with a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. 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- d. term goals for the patient. ANS: D The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see how today’s nursing actions can apply to the point the nurse wants the patient to reach at a future time. DIF: Cognitive Level: Applying (Application) REF: p. 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. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. 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 patient’s 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: p. 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 patient newly diagnosed with type 2 diabetes mellitus does not know how to check his a. own blood glucose levels with a glucometer. b. 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 c. agitation. 1. a = First-level priority problem 2. b = Second-level priority problem 3. c = Third-level priority problem 1. ANS: B DIF: Cognitive Level: Analyzing (Analysis) REF: p. 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 patient’s 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: p. 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 patient’s health but can be addressed after more urgent health problems are addressed (see Table 1-1). 3. ANS: A DIF: Cognitive Level: Analyzing (Analysis) REF: p. 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 patient’s health but can be addressed after more urgent health problems are addressed (see Table 1-1). Chapter 02: Cultural Competence Chapter 02: Cultural Competence Jarvis: Physical Examination & Health Assessment, 7th Edition MULTIPLE CHOICE 1. The nurse is reviewing the development of culture. Which statement is correct regarding the development of one’s culture? Culture is: a. Genetically determined on the basis of racial background. b. Learned through language acquisition and socialization. c. A nonspecific phenomenon and is adaptive but unnecessary. d. Biologically determined on the basis of physical characteristics. ANS: B Culture is learned from birth through language acquisition and socialization. It is not biologically or genetically determined and is learned by the individual. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 14 MSC: Client Needs: Psychosocial Integrity 2. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? a. Cultures are static and unchanging, despite changes around them. b. Cultures are never specific, which makes them hard to identify. c. Culture is most clearly reflected in a person’s language and behavior. d. Culture adapts to specific environmental factors and available natural resources. ANS: D Culture has four basic characteristics. Culture adapts to specific conditions related to environmental and technical factors and to the availability of natural resources, and it is dynamic and ever changing. Culture is learned from birth through the process of language acquisition and socialization, but it is not most clearly reflected in one’s language and behavior. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 14 MSC: Client Needs: Psychosocial Integrity 3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating “the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society” reflects which term? a. Mores b. Norms c. Culture d. Social learning ANS: C The culture that develops in any given society is always specific and distinctive, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit the given definition. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 14 MSC: Client Needs: Psychosocial Integrity 4. When discussing the use of the term subculture, the nurse recognizes that it is best described as: a. Fitting as many people into the majority culture as possible. b. Defining small groups of people who do not want to be identified with the larger culture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. Identifying fairly large groups of people with shared characteristics that are not common to d. all members of a culture. ANS: D Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 14 MSC: Client Needs: Psychosocial Integrity 5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: a. Hispanic. b. Black. c. Asian. d. American Indian. ANS: A Hispanics are the largest and fastest growing population in the United States, followed by Asians, Blacks, American Indians and Alaska natives, and other groups. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 11 MSC: Client Needs: General 6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospital’s safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary. ANS: A The nurse should inquire about the amulet’s meaning. Amulets, such as charms, are often considered an important means of protection from “evil spirits” by some cultures. DIF: Cognitive Level: Applying (Application) REF: p. 19 MSC: Client Needs: Psychosocial Integrity 7. The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? “The caregiver: a. Is able to speak the patient’s native language.” b. Possesses some basic knowledge of the patient’s cultural background.” Applies the proper background knowledge of a patient’s cultural background to provide the c. best possible health care.” d. Understands and attends to the total context of the patient’s situation.” ANS: D Culturally competent implies that the caregiver understands and attends to the total context of the individual’s situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. It does not require the caregiver to speak the patient’s native language. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24 MSC: Client Needs: Psychosocial Integrity 8. The nurse recognizes that an example of a person who is heritage consistent would be a: a. Woman who has adapted her clothing to the clothing style of her new country. b. Woman who follows the traditions that her mother followed regarding meals. c. Man who is not sure of his ancestor’s country of origin. d. Child who is not able to speak his parents’ native language. ANS: B Someone who is heritage consistent lives a lifestyle that reflects his or her traditional heritage, not the norms and customs of the new country. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 24 MSC: Client Needs: Psychosocial Integrity 9. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? a. “Ethnicity is dynamic and ever changing.” b. “Ethnicity is the belief in a higher power.” “Ethnicity pertains to a social group within the social system that claims shared values and c. traditions.” “Ethnicity is learned from birth through the processes of language acquisition and d. socialization.” ANS: C Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.Culture is dynamic, ever changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. DIF: Cognitive Level: Applying (Application) REF: p. 14 MSC: Client Needs: Psychosocial Integrity 10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of one’s spirituality? a. Belief in and the worship of God or gods b. Attendance at a specific church or place of worship c. Personal effort made to find purpose and meaning in life d. Being closely tied to one’s ethnic background ANS: C Spirituality refers to each person’s unique life experiences and his or her personal effort to find purpose and meaning in life. The other responses apply to religion. DIF: Cognitive Level: Applying (Application) REF: p. 15 MSC: Client Needs: Psychosocial Integrity 11. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation ANS: A Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture. This concept does not reflect heritage consistency. Biculturalism is a dual pattern of identification; acculturation is the process of adapting to and acquiring another culture. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 15 MSC: Client Needs: Psychosocial Integrity 12. The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. “What is your religion?” b. “Do you mostly participate in the religious traditions of your family?” c. “Do you smoke?” d. “Do you have a history of heart disease?” ANS: B Asking questions about participation in the religious traditions of family enables the nurse to assess a person’s heritage. Simply asking about one’s religion, smoking history, or health history does not reflect heritage. DIF: Cognitive Level: Applying (Application) REF: p. 24 MSC: Client Needs: Psychosocial Integrity 13. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans: a. Have less efficient immune systems and are often ill. b. Consider these symptoms part of normal living, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick. ANS: B The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 17 MSC: Client Needs: Psychosocial Integrity 14. The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? a. Holistic b. Biomedical c. Naturalistic d. Magicoreligious ANS: B Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic, or holistic, perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18 MSC: Client Needs: Psychosocial Integrity 15. An Asian-American woman is experiencing diarrhea, which is believed to be “cold” or “yin.” The nurse expects that the woman is likely to try to treat it with: a. Foods that are “hot” or “yang.” b. Readings and Eastern medicine meditations. c. High doses of medicines believed to be “cold.” d. No treatment is tried because diarrhea is an expected part of life. ANS: A Yin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. The other explanations do not reflect the yin/yang theory. DIF: Cognitive Level: Applying (Application) REF: p. 18 MSC: Client Needs: Psychosocial Integrity 16. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects “health” in an Asian with this belief? a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfect balance. d. A person is able to care for others and function socially. ANS: C Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 18 MSC: Client Needs: Psychosocial Integrity 17. Illness is considered part of life’s rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory? a. Naturalistic b. Biomedical c. Reductionist d. Magicoreligious ANS: A The naturalistic perspective states that the laws of nature create imbalances, chaos, and disease. From the perspective of the Chinese, for example, illness is not considered an introducing agent; rather, illness is considered a part of life’s rhythmic course and an outward sign of disharmony within. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18 MSC: Client Needs: Psychosocial Integrity 18. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: a. Germs and viruses. b. Supernatural forces. c. Eating imbalanced foods. d. An imbalance within his or her spiritual nature. ANS: B The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18 MSC: Client Needs: Psychosocial Integrity 19. If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she: a. Will comply with the treatment prescribed. b. Has obviously given up her belief in naturalistic causes of disease. c. May also be seeking the assistance of a shaman or medicine man. d. Will need extra help in dealing with her illness and may be experiencing a crisis of faith. ANS: C When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 19 MSC: Client Needs: Psychosocial Integrity 20. An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: a. Contact the hospital administrator about the best course of action. Automatically get a curandero for her, because requesting one herself is not culturally b. appropriate. Further assess the patient’s cultural beliefs and offer the patient assistance in contacting a c. curandero or priest if she desires. Ask the family what they would like to do because Mexican-Americans traditionally give d. control of decision making to their families. ANS: C In addition to seeking help from the biomedical or scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American-Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept). DIF: Cognitive Level: Analyzing (Analysis) REF: p. 19 MSC: Client Needs: Psychosocial Integrity 21. A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse’s best course of action? a. The nurse should focus on performing a full cardiac assessment. The nurse should focus on psychosomatic complaints because the patient has just learned b. that his wife has cancer. This patient is not in any danger at present; therefore, the nurse should send him home with c. instructions to contact his physician. It is unclear what is happening with this patient; consequently, the nurse should perform an d. assessment in both the physical and the psychosocial realms. ANS: D Wide cultural variations exist in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart). DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 17-18 MSC: Client Needs: Psychosocial Integrity 22. Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which of the following is a true statement regarding pain? Nurses’ attitudes toward their patients’ pain are unrelated to their own experiences with a. pain. b. Nurses need to recognize that many cultures practice silent suffering as a response to pain. A nurse’s area of clinical practice will most likely determine his or her assessment of a c. patient’s pain. A nurse’s years of clinical experience and current position are strong indicators of his or her d. response to patient pain. ANS: B Silent suffering is a potential response to pain in many cultures. The nurse’s assessment of pain needs to be embedded in a cultural context. The other responses are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 22 MSC: Client Needs: Psychosocial Integrity 23. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a. All patients will behave the same way when in pain. Just as patients vary in their perceptions of pain, so will they vary in their expressions of b. pain. Cultural norms have very little to do with pain tolerance, because pain tolerance is always c. biologically determined. A patient’s expression of pain is largely dependent on the amount of tissue injury associated d. with the pain. ANS: B In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 22 MSC: Client Needs: Psychosocial Integrity 24. During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? “Spirituality: a. Is a personal search to discover a supreme being.” Is an organized system of beliefs concerning the cause, nature, and purpose of the b. universe.” Is a belief that each person exists forever in some form, such as a belief in reincarnation or c. the afterlife.” Arises out of each person’s unique life experience and his or her personal effort to find d. purpose in life.” ANS: D Spirituality arises out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. The other definitions reflect the concept of religion. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 15 MSC: Client Needs: Psychosocial Integrity 25. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents’ perceptions of the illness. Parents are often the decision makers, and they have no knowledge of their children’s d. spiritual needs. ANS: A Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child’s developmental level and the religious climate that exists in the family. The other statements are not correct. MSC: Client Needs: Psychosocial Integrity 26. A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman’s sister until they can get a home of their own. When company arrives to visit with the woman’s sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak “perfect English.” This woman could be experiencing: a. Culture shock. b. Cultural taboos. c. Cultural unfamiliarity. d. Culture disorientation. ANS: A Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with the individual’s perceptions and expectations. The other terms are not correct. DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 21-22 MSC: Client Needs: Psychosocial Integrity 27. After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? “Self-care is: a. Not recognized as valuable by most health care providers.” b. Usually ineffective and may delay more effective treatment.” c. Always less expensive than biomedical alternatives.” d. Influenced by the accessibility of over-the-counter medicines.” ANS: D After a symptom is identified, the first effort at treatment is often self-care. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 19 28. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? The causation of illness is based on supernatural forces that influence the humors of the a. body. Herbs and medicines are classified on their physical characteristics of hot and cold and the b. humors of the body. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and c. social aspects of the individual. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to d. restore the balance of the humors of the body. ANS: D The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. The other statements are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18 MSC: Client Needs: Psychosocial Integrity 29. In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition? a. Patient with diabetes and renal failure b. Teenager with an abscessed tooth c. Child with symptoms of itching and a rash d. Older man with gastrointestinal discomfort ANS: D Illnesses believed to be caused by cold entering the body include earache, chest cramps, gastrointestinal discomfort, rheumatism, and tuberculosis. Those illnesses believed to be caused by heat, or overheating, include sore throats, abscessed teeth, rashes, and kidney disorders. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 18 MSC: Client Needs: Psychosocial Integrity 30. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient? a. “Are you of the Christian faith?” b. “Do you want to see a medicine man?” c. “How often do you seek help from medical providers?” d. “What cultural or spiritual beliefs are important to you?” ANS: D The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open- ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24 MSC: Client Needs: Psychosocial Integrity 31. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? a. Believing that illness is a punishment of sin b. Trying prayer before seeking medical help c. Refusing to accept blood products as part of treatment d. Stating that a child’s birth defect is the result of the parents’ sins ANS: C Cultural taboos are practices that are to be avoided, such as receiving blood products, eating pork, and consuming caffeine. The other answers do not reflect cultural taboos. DIF: Cognitive Level: Applying (Application) REF: p. 21 MSC: Client Needs: Psychosocial Integrity 32. The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: a. Family. b. Cultures. c. Spirituality. d. Subcultures. ANS: D Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 14 MSC: Client Needs: Psychosocial Integrity 33. The nurse is reviewing concepts related to one’s heritage and beliefs. The belief in divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as: a. Culture. b. Religion. c. Ethnicity. d. Spirituality. ANS: B Religion is defined as an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. Spirituality is born out of each person’s unique life experiences and his or her personal efforts to find purpose and meaning in life. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 15 MSC: Client Needs: Psychosocial Integrity 34. When planning a cultural assessment, the nurse should include which component? a. Family history b. Chief complaint c. Medical history d. Health-related beliefs ANS: D Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient’s history. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 24 MSC: Client Needs: Psychosocial Integrity 35. Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is: a. Being rewarded for good behavior. b. The balance of the body and spirit. c. Maintained by wearing jade amulets. d. Being in harmony with nature. ANS: D The belief that health is being in harmony with nature reflects the health beliefs of those of African heritages. The other examples represent Iberian and Central and South American heritages, American-Indian heritages, and Asian heritages (See Table 2-3). DIF: Cognitive Level: Analyzing (Analysis) REF: p. 20 MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply. a. Examine the patient within the context of one’s own cultural health and illness practices. b. Select questions that are not complex. c. Ask questions rapidly. d. Touch patients within the cultural boundaries of their heritage. e. Pace questions throughout the physical examination. ANS: B, D, E Patients should be examined within the context of their own cultural health and illness practices. Questions should be simply stated and not rapidly asked. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24 MSC: Client Needs: Psychosocial Integrity 2. The nurse is asking questions about a patient’s health beliefs. Which questions are appropriate? Select all that apply. a. “What is your definition of health?” b. “Does your family have a history of cancer?” c. “How do you describe illness?” d. “What did your mother do to keep you from getting sick?” e. “Have you ever had any surgeries?” f. “How do you keep yourself healthy?” ANS: A, C, D, F The questions listed are appropriate questions for an assessment of a patient’s health beliefs and practices. The questions regarding family history and surgeries are part of the patient’s physical history, not the patient’s health beliefs. DIF: Cognitive Level: Applying (Application) REF: p. 17 Chapter 03: The Interview Chapter 03: The Interview Jarvis: Physical Examination & Health Assessment, 7th Edition MULTIPLE CHOICE 1. 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. Not excited about her pregnancy but believes the nurse will negatively respond to her if she d. 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. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 28 MSC: Client Needs: Psychosocial Integrity 2. 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 Man with a hearing impairment who uses sign language to communicate and who has an d. 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. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 28 MSC: Client Needs: Psychosocial Integrity 3. The nurse makes which adjustment in the physical environment to promote the success of an interview? a. Reduces noise by turning off televisions and radios b. Reduces the distance between the interviewer and the patient to 2 feet or less c. Provides a dim light that makes the room cozy and helps the patient relax d. Arranges seating across a desk or table to allow the patient some personal space ANS: A The nurse should reduce noise by turning off the television, radio, and other unnecessary equipment, because multiple stimuli are confusing. The interviewer and patient should be approximately 4 to 5 feet apart; the room should be well-lit, enabling the interviewer and patient to see each other clearly. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. DIF: Cognitive Level: Applying (Application) REF: p. 29 MSC: Client Needs: Psychosocial Integrity 4. 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. Note-taking allows the patient to continue at his or her own pace as the nurse records what b. is said. Note-taking allows the nurse to shift attention away from the patient, resulting in an c. increased comfort level. Note-taking allows the nurse to break eye contact with the patient, which may increase his d. 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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 30 MSC: Client Needs: Psychosocial Integrity 5. 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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 31 MSC: Client Needs: Psychosocial Integrity 6. 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. DIF: Cognitive Level: Applying (Application) REF: p. 31 MSC: Client Needs: Psychosocial Integrity 7. 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 ANS: 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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 31 MSC: Client Needs: Psychosocial Integrity 8. A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. “Mr. Y., at your age, surely you have been hospitalized before!” b. “Mr. Y., I just need permission to get your medical records from County Medical.” “Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you c. tell me more about that?” “Mr. Y., I just need to get some additional information about your past hospitalizations. d. When was the last time you were admitted for chest pain?” ANS: D The nurse should use direct questions after the person’s opening narrative to fill in any details he or she left out. The nurse also should use direct questions when specific facts are needed, such as when asking about past health problems or during the review of systems. DIF: Cognitive Level: Applying (Application) REF: p. 31 MSC: Client Needs: Psychosocial Integrity 9. In using verbal responses to assist the patient’s narrative, some responses focus on the patient’s frame of reference and some focus on the health care provider’s perspective. An example of a verbal response that focuses on the health care provider’s perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation. ANS: D When the health care provider uses the response of confrontation, the frame of reference shifts from the patient’s perspective to the perspective of the health care provider, and the health care provider starts to express his or her own thoughts and feelings. Empathy, reflection, and facilitation responses focus on the patient’s frame of reference. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 32 MSC: Client Needs: Psychosocial Integrity 10. When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse’s best response to this behavior? a. Be silent, and allow him to continue when he is ready. Smile at him and say, “Don’t worry about all of this. I’m sure we can find out why you’re b. having these pains.” Lean back in the chair and ask, “You are looking at me kind of funny; there isn’t anything c. wrong, is there?” Stand up and say, “I can see that this interview is uncomfortable for you. We can continue it d. another time.” ANS: A Silent attentiveness communicates that the person has time to think and to organize what he or she wishes to say without an interruption from the nurse. Health professionals most often interrupt this thinking silence. The other responses are not conducive to ideal communication. DIF: Cognitive Level: Applying (Application) REF: p. 33 MSC: Client Needs: Psychosocial Integrity 11. A woman is discussing the problems she is having with her 2-year-old son. She says, “He won’t go to sleep at night, and during the day he has several fits. I get so upset when that happens.” The nurse’s best verbal response would be: a. “Go on, I’m listening.” b. “Fits? Tell me what you mean by this.” c. “Yes, it can be upsetting when a child has a fit.” d. “Don’t be upset when he has a fit; every 2 year old has fits.” ANS: B The nurse should use clarification when the person’s word choice is ambiguous or confusing (e.g., “Tell me what you mean by fits.”). Clarification is also used to summarize the person’s words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track. DIF: Cognitive Level: Applying (Application) REF: p. 33 MSC: Client Needs: Psychosocial Integrity 12. A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, “I can’t believe my boyfriend left me to do this by myself! What a terrible thing to do to me!” Which of these responses by the nurse uses empathy? a. “You feel alone.” b. “You can’t believe he left you alone?” c. “It must be so hard to face this all alone.” d. “I would be angry, too; raising a child alone is no picnic.” ANS: C An empathetic response recognizes the feeling and puts it into words. It names the feeling, allows its expression, and strengthens rapport. Other empathetic responses are, “This must be very hard for you,” “I understand,” or simply placing your hand on the person’s arm. Simply reflecting the person’s words or agreeing with the person i