Test Bank - Physical Examination and Health Assessment 8 edition (by Jarvis) Chapter 01: Evidence-Based Assessment,100% CORRECT

1. Aftercompletinganinitialassessmentofapatient,thenursehaschartedthathisrespirationsareeupneicand his pulse is 58 beats per minute. These types of data wouldbe: a. Objective. b. Reflective. c. Subjective. d. Introspective. ANS: A Objectivedataarewhatthehealthprofessionalobservesbyinspecting,percussing,palpating,andauscultating during the physical examination. Subjective data is what the person says about him or herself during history taking.Thetermsreflectiveandintrospectivearenotusedtodescribedata. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. ApatienttellsthenursethatheisverynervNouUsR,SisINnaGuTsBea.CteOdM,andfeelshot.Thesetypesofdatawouldbe: a. Objective. b. Reflective. c. Subjective. d. Introspective. ANS: C Subjectivedataarewhatthepersonsaysabouthimorherselfduringhistorytaking.Objectivedataarewhatthe health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination.Thetermsreflectiveandintrospectivearenotusedtodescribedata. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. Thepatientsrecord,laboratorystudies,objectivedata,andsubjectivedatacombinetoformthe: a. Database. b. Admittingdata. c. Financialstatement. d. Dischargesummary. ANS: A Togetherwiththepatientsrecordandlaboratorystudies,theobjectiveandsubjectivedataformthedatabase. Theotheritemsarenotpartofthepatientsrecord,laboratorystudies,ordata. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. Whenlisteningtoapatientsbreathsounds,thenurseisunsureofasoundthatisheard.Thenursesnext action should beto: a. Immediately notify the patientsphysician. b. Document the sound exactly as it washeard. c. Validatethedatabyaskingacoworkertolistentothebreathsounds. d. Assessagainin20minutestonotewhetherthesoundisstillpresent. ANS: C NURSINGTB.COM Whenunsureofasoundheardwhilelisteningtoapatientsbreathsounds,thenursevalidatesthedatatoensure accuracy.Ifthenursehaslessexperienceinanarea,thenheorsheasksanexperttolisten. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. Thenurseisconductingaclassfornewgraduatenurses.Duringtheteachingsession,thenurseshouldkeep inmindthatnovicenurses,withoutabackgroundofskillsandexperiencefromwhichtodraw,aremorelikely to make their decisionsusing: a. Intuition. b. A set ofrules. c. Articles injournals. d. Advice fromsupervisors. ANS: B Novicenursesoperatefromasetofdefined,structuredrules.Theexpertpractitionerusesintuitivelinks. DIF: Cognitive Level: Understanding(Comprehension) MSC: Client Needs: General 6. Expertnurseslearntoattendtoapatternofassessmentdataandactwithoutconsciouslylabelingit.These responses are referred toas: a. Intuition. b. The nursingprocess. c. Clinicalknowledge. d. Diagnosticreasoning. ANS: A Intuitionischaracterizedbypatternrecognitionexpertnurseslearntoattendtoapatternofassessmentdataand act without consciously labeling it. The other options are notcorrect. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs:General 7. Thenurseisreviewinginformationaboutevidence-basedpractice(EBP).Whichstatementbestreflects EBP? a. EBPreliesontraditionforsupportNoUfRbSesINtpGrTacBt.iCceOsM. b. EBPissimplytheuseofbestpracticetechniquesforthetreatmentofpatients. c. EBPemphasizestheuseofbestevidencewiththecliniciansexperience. d. ThepatientsownpreferencesarenotimportantwithEBP. ANS:C EBPisasystematicapproachtopracticethatemphasizestheuseofbestevidenceincombinationwiththe 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 traditionisimportantwhennocompellingandsupportiveresearchevidenceexists. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. Thenurseisconductingaclassonprioritysettingforagroupofnewgraduatenurses.Whichisanexample of a first-level priorityproblem? a. Patient with postoperativepain b. Newly diagnosed patient with diabetes who needs diabeticteaching c. Individual with a small laceration on the sole of thefoot d. Individualwithshortnessofbreathandrespiratorydistress ANS:D First-levelpriorityproblemsarethosethatareemergent,lifethreatening,andimmediate(e.g.,establishingan airway,supportingbreathing,maintainingcirculation,monitoringabnormalvitalsigns). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. Whenconsideringprioritysettingofproblems,thenursekeepsinmindthatsecond-levelpriorityproblems include which of theseaspects? a. Lowself-esteem b. Lack ofknowledge c. Abnormal laboratoryvalues d. Severely abnormal vitalsigns ANS: C NURSINGTB.COM Second-levelpriorityproblemsarethosethatrequirepromptinterventiontoforestallfurtherdeterioration(e.g., mentalstatuschange,acutepain,abnormallaboratoryvalues,riskstosafetyorsecurity). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. Whichcriticalthinkingskillhelpsthenurseseerelationshipsamongthedata? a. Validation b. Clustering relatedcues c. Identifying gaps indata d. Distinguishingrelevantfromirrelevant ANS:B Clusteringrelatedcueshelpsthenurseseerelationshipsamongthedata. DIF: Cognitive Level: Understanding(Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. Thenurseknowsthatdevelopingappropriatenursinginterventionsforapatientreliesonthe appropriatenessofthe diagnosis. a. Nursing b. Medical c. Admission d. Collaborative ANS:A Anaccuratenursingdiagnosisprovidesthebasisfortheselectionofnursinginterventionstoachieveoutcomes forwhichthenurseisaccountable.Theotheritemsdonotcontributetothedevelopmentofappropriatenursing interventions. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. Thenursingprocessisasequentialmethodofproblemsolvingthatnursesuseandincludeswhichsteps? a. Assessment, treatment, planning, evaluation, discharge, andfollow-up NURSINGTB.COM b. Admission, assessment, diagnosis, treatment, and dischargeplanning c. Admission, diagnosis, treatment, evaluation, and dischargeplanning d. Assessment,diagnosis,outcomeidentification,planning,implementation,andevaluation ANS:D Thenursingprocessisamethodofproblemsolvingthatincludesassessment,diagnosis,outcome identification, planning, implementation, andevaluation. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. Anewlyadmittedpatientisinacutepain,hasnotbeensleepingwelllately,andishavingdifficulty breathing. How should the nurse prioritize theseproblems? a. Breathing,pain,andsleep b. Breathing,sleep,andpain c. Sleep,breathing,andpain d. Sleep, pain, andbreathing ANS: A First-levelpriorityproblemsareimmediatepriorities,rememberingtheABCs(airway,breathing,and circulation),followedbysecond-levelproblems,andthenthird-levelproblems. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. Whichofthesewouldbeformulatedbyanurseusingdiagnosticreasoning? a. Nursingdiagnosis b. Medicaldiagnosis c. Diagnostichypothesis d. Diagnostic assessment ANS:C Diagnosticreasoningcallsforthenursetoformulateadiagnostichypothesis;thenursingprocesscallsfora nursingdiagnosis. NURSINGTB.COM DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs:General 15. Barriers to incorporating EBPinclude: a. Nurseslackofresearchskillsinevaluatingthequalityofresearchstudies. b. Lackofsignificantresearchstudies. c. Insufficientclinicalskillsofnurses. d. Inadequate physical assessmentskills. ANS: A Asindividuals,nurseslackresearchskillsinevaluatingthequalityofresearchstudies,areisolatedfromother colleagueswhoareknowledgeableinresearch,andoftenlackthetimetovisitthelibrarytoreadresearch.The other responses are not consideredbarriers. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs:General 16. Whatstepofthenursingprocessincludesdatacollectionbyhealthhistory,physicalexamination,and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment ANS:D Datacollection,includingperformingthehealthhistory,physicalexamination,andinterview,istheassessmen step of the nursingprocess. DIF:CognitiveLevel:Remembering(Knowledge) MSC: Client Needs:General 17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-basedclinicaldecisionmakingintotheirpractice.Whichsuggestionbythenursemanagerwould best help theseproblems? a. Form a committee to conduct researchstudies. b. PostpublishedresearchstudiesonNthUeRuSnINitsGbTuBll.CetOinMboards. c. Encourage the nurses to visit the library to reviewstudies. d. Teachthenurseshowtoconductelectronicsearchesforresearchstudies. ANS: D Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visitthelibrarymaynotbeavailableformanynurses.Actuallyconductingresearchstudiesmaybehelpfulin the long-run but not an immediate solution to reviewing existingresearch. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. Whenreviewingtheconceptsofhealth,thenurserecallsthatthecomponentsofholistichealthinclude which ofthese? a. Disease originates from the externalenvironment. b. The individual human is a closedsystem. c. Nurses are responsible for a patients healthstate. d. Holistic health views the mind, body, and spirit asinterdependent. ANS: D Considerationofthewholepersonistheessenceofholistichealth,whichviewsthemind,body,andspiritas interdependent.Thebasisofdiseaseoriginatesfromboththeexternalenvironmentandfromwithintheperson. Boththeindividualhumanandtheexternalenvironmentareopensystems,continuallychangingandadapting, andeachpersonisresponsibleforhisorherownpersonalhealthstate. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. Thenurserecognizesthattheconceptofpreventionindescribinghealthisessentialbecause: a. Disease can be prevented by treating the externalenvironment. b. ThemajorityofdeathsamongAmericansunderage65yearsarenotpreventable. c. Preventionplacestheemphasisonthelinkbetweenhealthandpersonalbehavior. d. Themeanstopreventionisthroughtreatmentprovidedbyprimaryhealthcarepractitioners. ANS: C AnaturalprogressiontopreventionroundsouNtUthReSpIrNesGeTnBtc.CoOncMeptofhealth.Guidelinestopreventionplace the emphasis on the link between health and personal behavior. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs:General 20. Thenurseisperformingaphysicalassessmentonanewlyadmittedpatient.Anexampleofobjective information obtained during the physical assessment includesthe: a. Patients history ofallergies. b. Patients use of medications athome. c. Last menstrual period 1 monthago. d. 2 5 cm scar on the right lowerforearm. ANS: D Objectivedataarethepatientsrecord,laboratorystudies,andconditionthatthehealthprofessionalobservesby inspecting,percussing,palpating,andauscultatingduringthephysicalexamination.Theotherresponsesreflect subjectivedata. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. Avisitingnurseismakinganinitialhomevisitforapatientwhohasmanychronicmedicalproblems. Whichtypeofdatabaseismostappropriatetocollectinthissetting? a. A follow-up data base to evaluate changes at appropriateintervals b. Anepisodicdatabasebecauseofthecontinuing,complexmedicalproblemsofthispatient c. Acompletehealthdatabasebecauseofthenursesprimaryresponsibilityformonitoringthe patientshealth d. Anemergencydatabasebecauseoftheneedtocollectinformationandmakeaccuratediagnoses rapidly ANS: C Thecompletedatabaseiscollectedinaprimarycaresetting,suchasapediatricorfamilypracticeclinic, independentorgroupprivatepractice,collegehealthservice,womenshealthcareagency,visitingnurse agency,orcommunityhealthagency.Inthesesettings,thenurseisthefirsthealthprofessionaltoseethe patientandhastheprimaryresponsibilityformonitoringthepersonshealthcare. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 22. WhichsituationismostappropriateduringNwUhRiScIhNtGheTBnu.CrsOeMperformsafocusedorproblem-centered history? a. Patient is admitted to a long-term carefacility. b. Patient has a sudden and severe shortness ofbreath. c. Patient is admitted to the hospital for surgery the followingday. d. Patient in an outpatient clinic has cold and influenza-likesymptoms. ANS: D Inafocusedorproblem-centereddatabase,thenursecollectsaminidatabase,whichissmallerinscopethan thecompleteddatabase.Thisminidatabaseprimarilyconcernsoneproblem,onecuecomplex,oronebody system. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 23. Apatientisattheclinictohaveherbloodpressurechecked.Shehasbeencomingtotheclinicweekly since she changed medications 2 months ago. The nurseshould: a. Collect a follow-up data base and then check her bloodpressure. b. Askhertoreadherhealthrecordandindicateanychangessinceherlastvisit. c. Checkonlyherbloodpressurebecausehercompletehealthhistorywasdocumented2monthsago. d. Obtainacompletehealthhistorybeforecheckingherbloodpressurebecausemuchofherhistory information may havechanged. ANS: A Afollow-updatabaseisusedinallsettingstofollowupshort-termorchronichealthproblems.Theother responses are not appropriate for thesituation. DIF:CognitiveLevel:Applying(Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 24. Apatientisbroughtbyambulancetotheemergencydepartmentwithmultipletraumasreceivedinan automobileaccident.Heisalertandcooperative,buthisinjuriesarequitesevere.Howwouldthenurse proceed with datacollection? a. Collecthistoryinformationfirst,thenperformthephysicalexaminationandinstitutelife-saving measures. b. Simultaneouslyaskhistoryquestionswhileperformingtheexaminationandinitiatinglife-saving measures. NURSINGTB.COM c. Collectallinformationonthehistoryform,includingsocialsupportpatterns,strengths,andcoping patterns. d. Performlife-savingmeasuresanddelayaskinganyhistoryquestionsuntilthepatientistransferred to the intensive careunit. ANS: B Theemergencydatabasecallsforarapidcollectionofthedatabase,oftenconcurrentlycompiledwithlife- saving measures. The other responses are not appropriate for thesituation. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 25. A42-year-oldpatientofAsiandescentisbeingseenattheclinicforaninitialexamination.Thenurse knowsthatincludingculturalinformationinhishealthassessmentisimportantto: a. Identify the cause of hisillness. b. Make accurate diseasediagnoses. c. Provide cultural health rights for theindividual. d. Provide culturally sensitive and appropriatecare. ANS: D Theinclusionofculturalconsiderationsinthehealthassessmentisofparamountimportancetogatheringdata thatareaccurateandmeaningfulandtointerveningwithculturallysensitiveandappropriatecare. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 26. Inthehealthpromotionmodel,thefocusofthehealthprofessionalincludes: a. Changing the patients perceptions ofdisease. b. Identifying biomedical modelinterventions. c. Identifying negative health acts of theconsumer. d. Helping the consumer choose a healthierlifestyle. ANS: D Inthehealthpromotionmodel,thefocusofthehealthprofessionalisonhelpingtheconsumerchoosea healthierlifestyle. NURSINGTB.COM DIF: Cognitive Level: Remembering (Knowledge) MSC:ClientNeeds:HealthPromotionandMaintenance 27. Thenursehasimplementedseveralplannedinterventionstoaddressthenursingdiagnosisofacutepain. Which would be the next appropriateaction? a. Establishpriorities. b. Identify expectedoutcomes. c. Evaluatetheindividualscondition,andcompareactualoutcomeswithexpectedoutcomes. d. Interpret data, and then identify clusters of cues and makeinferences. ANS: C Evaluationisthenextstepaftertheimplementationphaseofthenursingprocess.Duringthisstep,thenurse evaluatestheindividualsconditionandcomparestheactualoutcomeswithexpectedoutcomes. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 28. Whichstatementbestdescribesaproficientnurse?Aproficientnurseisonewho: a. Haslittleexperiencewithaspecifiedpopulationandusesrulestoguideperformance. b. Hasanintuitivegraspofaclinicalsituationandquicklyidentifiestheaccuratesolution. c. Sees actions in the context of daily plans forpatients. d. Understandsapatientsituationasawholeratherthanalistoftasksandrecognizesthelong-term goals for thepatient. ANS: D The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situationasawholeratherthanasalistoftasks.Theproficientnurseisabletoseehowtodaysnursingactions canapplytothepointthenursewantsthepatienttoreachatafuturetime. DIF:CognitiveLevel:Applying(Application) MSC: Client Needs:General MULTIPLE RESPONSE 1.Thenurseisreviewingdatacollectedafteranassessment.Ofthedatalistedbelow,whichwouldbe consideredrelatedcuesthatwouldbeclusteredtogetherduringdataanalysis?Selectallthatapply. a. Inspiratory wheezes noted in left lowerlobes NURSINGTB.COM b. Hypoactive bowelsounds c. Nonproductivecough d. Edema, +2, noted on lefthand e. Patient reports dyspnea uponexertion f. Rateofrespirations16breathsperminute ANS: A, C, E,F Clusteringrelatedcueshelpthenurserecognizerelationshipsamongthedata.Thecuesrelatedtothepatients respiratorystatus(e.g.,wheezes,cough,reportofdyspnea,respirationrateandrhythm)areallrelated.Cues relatedtobowelsandperipheraledemaarenotrelatedtotherespiratorycues. DIF: Cognitive Level: Analyzing (Analysis) 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. Apatientnewlydiagnosedwithtype2diabetesmellitusdoesnotknowhowtocheckhisown blood glucose levels with aglucometer. b. Ateenagerwhowasstungbyabeeduringasoccermatchishavingtroublebreathing. c. Anolderadultwithaurinarytractinfectionisalsoshowingsignsofconfusionandagitation. 1. a = First-level priorityproblem 2. b = Second-level priorityproblem 3. c = Third-level priorityproblem 1. ANS: B DIF: Cognitive Level: Analyzing(Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT:First-levelpriorityproblemsareimmediatepriorities,suchastroublebreathing(remembertheairway, breathing,circulationpriorities).Second-levelpriorityproblemsarenextinurgency,butnotlife-threatening. Third-levelpriorities(e.g.,patienteducation)areimportanttoapatientshealthbutcanbeaddressedaftermore urgent health problems areaddressed. 2. ANS: C DIF: Cognitive Level: Analyzing(Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT:First-levelpriorityproblemsareimmediatepriorities,suchastroublebreathing(remembertheairway, breathing,circulationpriorities).Second-levelpriorityproblemsarenextinurgency,butnotlife-threatening. Third-levelpriorities(e.g.,patienteducation)NarUeRimSIpNoGrtTanBt.CtoOaMpatientshealthbutcanbeaddressedaftermore urgent health problems are addressed. 3. ANS: A DIF: Cognitive Level: Analyzing(Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT:First-levelpriorityproblemsareimmediatepriorities,suchastroublebreathing(remembertheairway, breathing,circulationpriorities).Second-levelpriorityproblemsarenextinurgency,butnotlife-threatening. Third-levelpriorities(e.g.,patienteducation)areimportanttoapatientshealthbutcanbeaddressedaftermore urgent health problems areaddressed. Chapter 02: Cultural Assessment MULTIPLECHOICE 1. Thenurseisreviewingthedevelopmentofculture.Whichstatementiscorrectregardingthedevelopmentof ones culture? Cultureis: a. Genetically determined on the basis of racialbackground. b. Learned through language acquisition andsocialization. c. A nonspecific phenomenon and is adaptive butunnecessary. d. Biologically determined on the basis of physicalcharacteristics. ANS: B Cultureislearnedfrombirththroughlanguageacquisitionandsocialization.Itisnotbiologicallyor genetically determined and is learned by theindividual. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 2. Duringaclassontheaspectsofculture,thenursesharesthatculturehasfourbasiccharacteristics.Which statement correctly reflects one of thesecharacteristics? NURSINGTB.COM a. Cultures are static and unchanging, despite changes aroundthem. b. Cultures are never specific, which makes them hard toidentify. c. Culture is most clearly reflected in a persons language andbehavior. d. Cultureadaptstospecificenvironmentalfactorsandavailablenaturalresources. ANS: D Culture has four basic characteristics. Culture adapts to specific conditions related to environmental and technicalfactorsandtotheavailabilityofnaturalresources,anditisdynamicandeverchanging.Cultureis learned from birth through the process of language acquisition and socialization, but it is not most clearly reflected in ones language andbehavior. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 3. Duringaseminaronculturalaspectsofnursing,thenurserecognizesthatthedefinitionstatingthespecific anddistinctknowledge,beliefs,skills,andcustomsacquiredbymembersofasocietyreflectswhichterm? a. Mores b. Norms c. Culture d. Sociallearning ANS:C Theculturethatdevelopsinanygivensocietyisalwaysspecificanddistinctive,encompassingallofthe knowledge,beliefs,customs,andskillsacquiredbymembersofthesociety.Theothertermsdonotfitthe givendefinition. DIF:CognitiveLevel:Remembering(Knowledge) MSC: Client Needs: PsychosocialIntegrity 4. Whendiscussingtheuseofthetermsubculture,thenurserecognizesthatitisbestdescribedas: a. Fitting as many people into the majority culture aspossible. b. Definingsmallgroupsofpeoplewhodonotwanttobeidentifiedwiththelargerculture. c. Singlingoutgroupsofpeoplewhosufferdifferentialandunequaltreatmentasaresultofcultural variations. NURSINGTB.COM d. Identifyingfairlylargegroupsofpeoplewithsharedcharacteristicsthatarenotcommontoall members of a culture. ANS: D Withincultures,groupsofpeoplesharedifferentbeliefs,values,andattitudes.Differencesoccurbecauseof ethnicity,religion,education,occupation,age,andgender.Whensuchgroupsfunctionwithinalargeculture, they are referred to as subculturalgroups. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 5. WhenreviewingthedemographicsofethnicgroupsintheUnitedStates,thenurserecallsthatthelargest and fastest growing populationis: a. Hispanic. b. Black. c. Asian. d. AmericanIndian. ANS: A HispanicsarethelargestandfastestgrowingpopulationintheUnitedStates,followedbyAsians,Blacks, American Indians and Alaska natives, and othergroups. DIF:CognitiveLevel:Remembering(Knowledge) MSC: Client Needs:General 6. Duringanassessment,thenursenoticesthatapatientishandlingasmallcharmthatistiedtoaleatherstrip around his neck. Which action by the nurse isappropriate? a. Ask the patient about the item and itssignificance. b. Askthepatienttolocktheitemwithothervaluablesinthehospitalssafe. c. Tell the patient that a family member should take valuableshome. d. No action isnecessary. ANS: A Thenurseshouldinquireabouttheamuletsmeaning.Amulets,suchascharms,areoftenconsideredan important means of protection from evil spirits by somecultures. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity NURSINGTB.COM 7. Thenursemanagerisexplainingculturallycompetentcareduringastaffmeeting.Whichstatement accurately describes the concept of culturally competent care? The caregiver: a. Is able to speak the patients nativelanguage. b. Possesses some basic knowledge of the patients culturalbackground. c. Appliestheproperbackgroundknowledgeofapatientsculturalbackgroundtoprovidethebest possible healthcare. d. Understands and attends to the total context of the patientssituation. ANS: D Culturallycompetentimpliesthatthecaregiverunderstandsandattendstothetotalcontextoftheindividuals situation.Thiscompetencyincludesawarenessofimmigrationstatus,stressfactors,othersocialfactors,and culturalsimilaritiesanddifferences.Itdoesnotrequirethecaregivertospeakthepatientsnativelanguage. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 8. Thenurserecognizesthatanexampleofapersonwhoisheritageconsistentwouldbea: a. Womanwhohasadaptedherclothingtotheclothingstyleofhernewcountry. b. Womanwhofollowsthetraditionsthathermotherfollowedregardingmeals. c. Man who is not sure of his ancestors country oforigin. d. Child who is not able to speak his parents nativelanguage. ANS: B Someonewhoisheritageconsistentlivesalifestylethatreflectshisorhertraditionalheritage,notthenorms and customs of the newcountry. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 9. Afteraclassoncultureandethnicity,thenewgraduatenursereflectsacorrectunderstandingoftheconcept of ethnicity with whichstatement? a. Ethnicityisdynamicandeverchanging. b. Ethnicityisthebeliefinahigherpower. c. Ethnicitypertainstoasocialgroupwithinthesocialsystemthatclaimssharedvaluesand traditions. NURSINGTB.COM d. Ethnicityislearnedfrombirththroughtheprocessesoflanguageacquisitionandsocialization. ANS: C Ethnicitypertainstoasocialgroupwithinthesocialsystemthatclaimstohavevariabletraits,suchasa commongeographicorigin,migratorystatus,religion,race,language,values,traditions,symbols,orfood preferences.Cultureisdynamic,everchanging,andlearnedfrombirththroughtheprocessesoflanguage acquisition and socialization. Religion is the belief in a higherpower. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 10. Thenurseiscomparingtheconceptsofreligionandspirituality.Whichofthefollowingisanappropriate component of onesspirituality? a. Belief in and the worship of God orgods b. Attendance at a specific church or place ofworship c. Personal effort made to find purpose and meaning inlife d. Being closely tied to ones ethnicbackground ANS: C Spiritualityreferstoeachpersonsuniquelifeexperiencesandhisorherpersonalefforttofindpurposeand meaning in life. The other responses apply toreligion. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 11. A woman who has lived in the United States for a year after moving from Europe has learned to speak Englishandisalmostfinishedwithhercollegestudies.Shenowdresseslikeherpeersandsaysthatherfamily inEuropewouldhardlyrecognizeher.Thisnurserecognizesthatthissituationillustrateswhichconcept? a. Assimilation b. Heritageconsistency c. Biculturalism d. Acculturation ANS:A Assimilationistheprocessbywhichapersondevelopsanewculturalidentityandbecomeslikemembersof the dominant culture. This concept does not reflect heritage consistency. Biculturalism is a dual pattern of identification;acculturationistheprocessofadaptingtoandacquiringanotherculture. NURSINGTB.COM DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 12. Thenurseisconductingaheritageassessment.Whichquestionismostappropriateforthisassessment? a. What is yourreligion? b. Do you mostly participate in the religious traditions of yourfamily? c. Do yousmoke? d. Do you have a history of heartdisease? ANS: B Askingquestionsaboutparticipationinthereligioustraditionsoffamilyenablesthenursetoassessapersons heritage.Simplyaskingaboutonesreligion,smokinghistory,orhealthhistorydoesnotreflectheritage. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 13. InthemajoritycultureofAmerica,coughing,sweating,anddiarrheaaresymptomsofanillness.Forsome individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably becauseMexican-Americans: a. Have less efficient immune systems and are oftenill. b. Considerthesesymptomspartofnormalliving,notsymptomsofillhealth. c. Come from Mexico, and coughing is normal and healthythere. d. Areusuallyinalowersocioeconomicgroupandaremorelikelytobesick. ANS: B Thenurseneedstoidentifythemeaningofhealthtothepatient,rememberingthatconceptsarederived,in part,fromthewayinwhichmembersoftheculturalgroupdefinehealth. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 14. Thenurseisreviewingtheoriesofillness.Thegermtheory,whichstatesthatmicroscopicorganismssuch 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 NURSINGTB.COM ANS: B Amongthebiomedicalexplanationsfordiseaseisthegermtheory,whichstatesthatmicroscopicorganisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic, or holistic, perspectiveholdsthattheforcesofnaturemustbekeptinnaturalbalance.Themagicoreligiousperspective holds that supernatural forces dominate and cause illness orhealth. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 15. AnAsian-Americanwomanisexperiencingdiarrhea,whichisbelievedtobecoldoryin.Thenurse expects that the woman is likely to try to treat itwith: a. Foods that are hot oryang. b. Readings and Eastern medicinemeditations. c. High doses of medicines believed to becold. d. No treatment is tried because diarrhea is an expected part oflife. ANS: A Yinfoodsarecoldandyangfoodsarehot.Coldfoodsareeatenwithahotillness,andhotfoodsareeatenwith a cold illness. The other explanations do not reflect the yin/yangtheory. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 16. ManyAsiansbelieveintheyin/yangtheory,whichisrootedintheancientChinesephilosophyofTao. WhichstatementmostaccuratelyreflectshealthinanAsianwiththisbelief? a. A person is able to work andproduce. b. A person is happy, stable, and feelsgood. c. All aspects of the person are in perfectbalance. d. A person is able to care for others and functionsocially. ANS: C ManyAsiansbelieveintheyin/yangtheory,inwhichhealthisbelievedtoexistwhenallaspectsoftheperson are in perfect balance. The other statements do not describe thistheory. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PsychosocialIntegrity NURSINGTB.COM 17. Illnessisconsideredpartoflifesrhythmiccourseandisanoutwardsignofdisharmonywithin.This statementmostaccuratelyreflectstheviewsaboutillnessfromwhichtheory? 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 consideredapartoflifesrhythmiccourseandanoutwardsignofdisharmonywithin.Theotheroptionsarenot correct. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 18. Anindividualwhotakesthemagicoreligiousperspectiveofillnessanddiseaseislikelytobelievethathis or her illness was causedby: a. Germs andviruses. b. Supernaturalforces. c. Eating imbalancedfoods. d. An imbalance within his or her spiritualnature. ANS: B Thebasicpremiseofthemagicoreligiousperspectiveisthattheworldisseenasanarenainwhichsupernatura forcesdominate.Thefateoftheworldandthoseinitdependsontheactionsofsupernaturalforcesforgoodor evil. The other answers do not reflect the magicoreligiousperspective. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 19. IfanAmericanIndianwomanhascometotheclinictoseekhelpwithregulatingherdiabetes,thenthe nurse can expect thatshe: a. Will comply with the treatmentprescribed. NURSINGTB.COM b. Has obviously given up her belief in naturalistic causes ofdisease. c. May also be seeking the assistance of a shaman or medicineman. d. Willneedextrahelpindealingwithherillnessandmaybeexperiencingacrisisoffaith. ANS: C Whenself-treatmentisunsuccessful,theindividualmayturntothelayorfolkhealingsystems,tospiritualor religioushealing,ortoscientificbiomedicine.Inadditiontoseekinghelpfromabiomedicalorscientifichealth care provider, patients may also seek help from folk or religioushealers. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 20. AnolderMexican-Americanwomanwithtraditionalbeliefshasbeenadmittedtoaninpatientcareunit.A culturally sensitive nursewould: a. Contact the hospital administrator about the best course ofaction. b. Automaticallygetacuranderoforher,becauserequestingoneherselfisnotculturallyappropriate. c. Furtherassessthepatientsculturalbeliefsandofferthepatientassistanceincontactingacurandero or priest if she desires. d. AskthefamilywhattheywouldliketodobecauseMexican-Americanstraditionallygivecontrol of decision making to theirfamilies. ANS: C Inadditiontoseekinghelpfromthebiomedicalorscientifichealthcareprovider,patientsmayalsoseekhelp fromfolkorreligioushealers.Somepeople,suchasthoseofMexican-AmericanorAmerican-Indianorigins, maybelievethatthecureisincompleteunlessthebody,mind,andspiritarealsohealed(althoughthedivision of the person into parts is a Westernconcept). DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 21. A63-year-oldChinese-Americanmanentersthehospitalwithcomplaintsofchestpain,shortnessof breath,andpalpitations.Whichstatementmostaccuratelyreflectsthenursesbestcourseofaction? a. The nurse should focus on performing a full cardiacassessment. b. Thenurseshouldfocusonpsychosomaticcomplaintsbecausethepatienthasjustlearnedthathis wife hascancer. c. Thispatientisnotinanydangeratpresent;therefore,thenurseshouldsendhimhomewith instructions to contact hisphysician. NURSINGTB.COM d. Itisunclearwhatishappeningwiththispatient;consequently,thenurseshouldperforman assessment in both the physical and the psychosocialrealms. ANS: D Wideculturalvariationsexistinthemannerinwhichcertainsymptomsanddiseaseconditionsareperceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states into bodilysymptoms(e.g.,complainingofcardiacsymptomsbecausethecenterofemotionintheChineseculture is theheart). DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 22. Symptoms,suchaspain,areofteninfluencedbyapersonsculturalheritage.Whichofthefollowingisa true statement regarding pain? a. Nursesattitudestowardtheirpatientspainareunrelatedtotheirownexperienceswithpain. b. Nursesneedtorecognizethatmanyculturespracticesilentsufferingasaresponsetopain. c. Anursesareaofclinicalpracticewillmostlikelydeterminehisorherassessmentofapatients pain. d. Anursesyearsofclinicalexperienceandcurrentpositionarestrongindicatorsofhisorher response to patient pain. ANS: B Silentsufferingisapotentialresponsetopaininmanycultures.Thenursesassessmentofpainneedstobe embedded in a cultural context. The other responses are notcorrect. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 23. Thenurseisreviewingconceptsofculturalaspectsofpain.Whichstatementistrueregardingpain? a. All patients will behave the same way when inpain. b. Justaspatientsvaryintheirperceptionsofpain,sowilltheyvaryintheirexpressionsofpain. c. Culturalnormshaveverylittletodowithpaintolerance,becausepaintoleranceisalways biologicallydetermined. d. Apatientsexpressionofpainislargelydependentontheamountoftissueinjuryassociatedwith thepain. ANS: B Inadditiontoexpectingvariationsinpainperceptionandtolerance,thenurseshouldexpectvariationsinthe expressionofpain.ItiswellknownthatindiNURSINGTB.COMsocialenvironmentforvalidationand comparison. The other statements are incorrect. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 24. Duringaclassonreligionandspirituality,thenurseisaskedtodefinespirituality.Whichansweris correct?Spirituality: a. Is a personal search to discover a supremebeing. b. Isanorganizedsystemofbeliefsconcerningthecause,nature,andpurposeoftheuniverse. c. Isabeliefthateachpersonexistsforeverinsomeform,suchasabeliefinreincarnationorthe afterlife. d. Arisesoutofeachpersonsuniquelifeexperienceandhisorherpersonalefforttofindpurposein life. ANS: D Spiritualityarisesoutofeachpersonsuniquelifeexperienceandhisorherpersonalefforttofindpurposeand meaning in life. The other definitions reflect the concept ofreligion. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 25. Thenurserecognizesthatworkingwithchildrenwithadifferentculturalperspectivemaybeespecially difficultbecause: a. Childrenhavespiritualneedsthatareinfluencedbytheirstagesofdevelopment. b. Childrenhavespiritualneedsthataredirectreflectionsofwhatisoccurringintheirhomes. c. Religious beliefs rarely affect the parents perceptions of theillness. d. Parentsareoftenthedecisionmakers,andtheyhavenoknowledgeoftheirchildrensspiritual needs. ANS: A Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritualneedsthatvaryaccordingtothechildsdevelopmentallevelandthereligiousclimatethatexistsinthe family. The other statements are notcorrect. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 26. A30-year-oldwomanhasrecentlymovedtotheUnitedStateswithherhusband.Theyarelivingwiththe womanssisteruntiltheycangetahomeoftheirown.Whencompanyarrivestovisitwiththewomanssister, thewomanfeelssuddenlyshyandretreatstotNhUeRbaScINkGbeTdBr.oCoOmMtohideuntilthecompanyleaves.Sheexplains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could beexperiencing: a. Cultureshock. b. Culturaltaboos. c. Culturalunfamiliarity. d. Culturedisorientation. ANS: A Cultureshockisatermusedtodescribethestateofdisorientationorinabilitytorespondtothebehaviorofa different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with the individuals perceptions and expectations. The other terms are notcorrect. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 27. Afterasymptomisrecognized,thefirsteffortattreatmentisoftenself-care.Whichofthefollowing statements about self-care is true? Self-careis: a. Not recognized as valuable by most health careproviders. b. Usually ineffective and may delay more effectivetreatment. c. Always less expensive than biomedicalalternatives. d. Influenced by the accessibility of over-the-countermedicines. ANS: D Afterasymptomisidentified,thefirsteffortattreatmentisoftenself-care.Theavailabilityofover-the-counter medications, the relatively high literacy level of Americans, and the influence of the mass media in communicatinghealth-relatedinformationtothegeneralpopulationhavecontributedtothehighpercentageof cases ofself-treatment. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 28. Thenurseisreviewingthehot/coldtheoryofhealthandillness.Whichstatementbestdescribesthebasic tenets of thistheory? a. Thecausationofillnessisbasedonsupernaturalforcesthatinfluencethehumorsofthebody. b. Herbsandmedicinesareclassifiedontheirphysicalcharacteristicsofhotandcoldandthehumors of thebody. NURSINGTB.COM c. Thefourhumorsofthebodyconsistofblood,yellowbile,spiritualconnectedness,andsocial aspects of theindividual. d. Thetreatmentofdiseaseconsistsofaddingorsubtractingcold,heat,dryness,orwetnesstorestore the balance of the humors of thebody. ANS: D Thehot/coldtheoryofhealthandillnessisbasedonthefourhumorsofthebody:blood,phlegm,blackbile, andyellowbile.Thesehumorsregulatethebasicbodilyfunctions,describedintermsoftemperature,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 notcorrect. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 29. Inthehot/coldtheory,illnessesarebelievedtobecausedbyhotorcoldenteringthebody.Whichofthese patient conditions is most consistent with a coldcondition? a. Patient with diabetes and renalfailure b. Teenager with an abscessedtooth c. Child with symptoms of itching and arash d. Older man with gastrointestinaldiscomfort ANS: D Illnessesbelievedtobecausedbycoldenteringthebodyincludeearache,chestcramps,gastrointestinal discomfort,rheumatism,andtuberculosis.Thoseillnessesbelievedtobecausedbyheat,oroverheating, include sore throats, abscessed teeth, rashes, and kidneydisorders. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 30. Whenprovidingculturallycompetentcare,nursesmustincorporateculturalassessmentsintotheirhealth assessments.Whichstatementismostappropriatetousewheninitiatinganassessmentofculturalbeliefswith an older American-Indianpatient? a. Are you of the Christianfaith? b. Do you want to see a medicineman? c. How often do you seek help from medicalproviders? d. What cultural or spiritual beliefs are important toyou? ANS: D NURSINGTB.COM The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistancefromamedicinemanorshaman,butthenurseshouldnotassumethis.Anopen-endedquestion regardingculturalandspiritualbeliefsisbestusedinitiallywhenperformingaculturalassessment. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 31. Duringaclassonculturalpractices,thenursehearsthetermculturaltaboo.Whichstatementillustratesthe concept of a culturaltaboo? a. Believing that illness is a punishment ofsin b. Trying prayer before seeking medicalhelp c. Refusing to accept blood products as part oftreatment d. Statingthatachildsbirthdefectistheresultoftheparentssins ANS:C Culturaltaboosarepracticesthataretobeavoided,suchasreceivingbloodproducts,eatingpork,and consuming caffeine. The other answers do not reflect culturaltaboos. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 32. Thenurserecognizesthatcategoriessuchasethnicity,gender,andreligionillustratetheconceptof: a. Family. b. Cultures. c. Spirituality. d. Subcultures. ANS: D Withincultures,groupsofpeoplesharedifferentbeliefs,values,andattitudes.Differencesoccurbecauseof ethnicity,religion,education,occupation,age,andgender.Whensuchgroupsfunctionwithinalargeculture, they are referred to as subculturalgroups. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 33. Thenurseisreviewingconceptsrelatedtoonesheritageandbeliefs.Thebeliefindivineorsuperhuman power(s)tobeobeyedandworshippedasthecreator(s)andruler(s)oftheuniverseisknownas: a. Culture. b. Religion. c. Ethnicity. d. Spirituality. NURSINGTB.COM ANS: B Religionisdefinedasanorganizedsystemofbeliefsconcerningthecause,nature,andpurposeoftheuniverse, especially belief in or the worship of God or gods. Spirituality is born out of each persons 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, andothers. DIF:CognitiveLevel:Remembering(Knowledge) MSC: Client Needs: PsychosocialIntegrity 34. Whenplanningaculturalassessment,thenurseshouldincludewhichcomponent? a. Familyhistory b. Chiefcomplaint c. Medicalhistory d. Health-related beliefs ANS:D Health-relatedbeliefsandpracticesareonecomponentofaculturalassessment.Theotheritemsreflectother aspects of the patientshistory. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 35. WhichofthefollowingreflectsthetraditionalhealthandillnessbeliefsandpracticesofthoseofAfrican heritage? Healthis: a. Beingrewardedforgoodbehavior. b. Thebalanceofthebodyandspirit. c. Maintained by wearing jadeamulets. d. Being in harmony withnature. ANS: D NURSINGTB.COM ThebeliefthathealthisbeinginharmonywithnaturereflectsthehealthbeliefsofthoseofAfricanheritages. TheotherexamplesrepresentIberianandCentralandSouthAmericanheritages,American-Indianheritages, and Asianheritages. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. Thenurseisreviewingaspectsofculturalcare.Whichstatementsillustrateproperculturalcare?Selectall thatapply. a. Examinethepatientwithinthecontextofonesownculturalhealthandillnesspractices. b. Select questions that are notcomplex. c. Ask questionsrapidly. d. Touch patients within the cultural boundaries of theirheritage. e. Pace questions throughout the physicalexamination. ANS: B, D, E Patientsshouldbeexaminedwithinthecontextoftheirownculturalhealthandillnesspractices.Questions should be simply stated and not rapidlyasked. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 2. Thenurseisaskingquestionsaboutapatientshealthbeliefs.Whichquestionsareappropriate?Selectallthat apply. a. What is your definition ofhealth? b. Does your family have a history ofcancer? c. How do you describeillness? d. What did your mother do to keep you from gettingsick? e. Have you ever had anysurgeries? f. How do you keep yourselfhealthy? ANS: A, C, D, F Thequestionslistedareappropriatequestionsforanassessmentofapatientshealthbeliefsandpractices.The questionsregardingfamilyhistoryandsurgerNURSINGTB.COMtientsphysicalhistory,notthepatientshealth beliefs. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity Chapter 03: The Interview MULTIPLE CHOICE 1. Thenurseisconductinganinterviewwithawomanwhohasrecentlylearnedthatsheispregnantandwho has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited aboutthepregnancybuthaveafewquestions.Shelooksnervouslyatherhandsduringtheinterviewandsighs loudly.Consideringtheconceptofcommunication,whichstatementdoesthenurseknowtobemostaccurate? The womanis: a. Excited about her pregnancy but nervous about thelabor. b. Exhibiting verbal and nonverbal behaviors that do notmatch. c. Excitedaboutherpregnancy,butherhusbandisnotandthisisupsettingtoher. d. Notexcitedaboutherpregnancybutbelievesthenursewillnegativelyrespondtoherifshestates this. ANS: B Communication is all behaviors, conscious and unconscious, verbal and nonverbal. All behaviors have meaning.Herbehaviordoesnotimplythatsheisnervousaboutlabor,upsetbyherhusband,orworriedabout the nursesresponse. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PsychosocialIntegrity NURSINGTB.COM 2. Receivingisapartofthecommunicationprocess.Whichreceiverismostlikelytomisinterpretamessage sent by a health careprofessional? a. Well-adjusted adolescent who came in for a sportsphysical b. Recovering alcoholic who came in for a basic physicalexamination c. Man whose wife has just been diagnosed with lungcancer d. Manwithahearingimpairmentwhousessignlanguagetocommunicateandwhohasan interpreter withhim ANS: C Thereceiverattachesmeaningdeterminedbyhisorherexperiences,culture,self-concept,andcurrentphysical and emotional states. The man whose wife has just been diagnosed with lung cancer may be experiencing emotions that affect hisreceiving. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 3. Thenursemakeswhichadjustmentinthephysicalenvironmenttopromotethesuccessofaninterview? a. Reduces noise by turning off televisions andradios b. Reducesthedistancebetweentheinterviewerandthepatientto2feetorless c. Providesadimlightthatmakestheroomcozyandhelpsthepatientrelax d. Arrangesseatingacrossadeskortabletoallowthepatientsomepersonalspace ANS:A Thenurseshouldreducenoisebyturningoffthetelevision,radio,andotherunnecessaryequipment,because multiplestimuliareconfusing.Theinterviewerandpatientshouldbeapproximately4to5feetapart;theroom should be well-lit, enabling the interviewer and patient to see each other clearly. Having a table or desk in betweenthetwopeoplecreatestheideaofabarrier;equal-statusseating,ateyelevel,isbetter. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 4. Inaninterview,thenursemayfinditnecessarytotakenotestoaidhisorhermemorylater.Which statement is true regardingnote-taking? a. Note-takingmayimpedethenursesobservationofthepatientsnonverbalbehaviors. b. Note-takingallowsthepatienttocNonUtRinSuIeNaGtThBis.CoOrMherownpaceasthenurserecordswhatissaid. c. Note-takingallowsthenursetoshiftattentionawayfromthepatient,resultinginanincreased comfortlevel. d. Note-takingallowsthenursetobreakeyecontactwiththepatient,whichmayincreasehisorher level ofcomfort. ANS: A Theuseofhistoryformsandnote-takingmaybeunavoidable.However,thenursemustbeawarethatnote- taking during the interview has disadvantages. It breaks eye contact too often and shifts the attention away fromthepatient,whichdiminisheshisorhersenseofimportance.Note-takingmayalsointerruptthepatients narrativeflow,anditimpedestheobservationofthepatientsnonverbalbehavior. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 5. Thenurseasks,Iwouldliketoaskyousomequestionsaboutyourhealthandyourusualdailyactivitiesso thatwecanbetterplanyourstayhere.Thisquestionisfoundatthe phase of the interview process. a. Summary b. Closing c. Body d. Openingorintroduction ANS:D Whengatheringacompletehistory,thenurseshouldgivethereasonfortheinterviewduringtheopeningor introductionphaseoftheinterview,notduringorattheendoftheinterview. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 6. Awomanhasjustenteredtheemergencydepartmentafterbeingbatteredbyherhusband.Thenurseneeds to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with thispatient? a. Hello, Nancy, my name is Mrs.C. b. Hello, Mrs. H., my name is Mrs. C. It sure is coldtoday! c. Mrs. H., my name is Mrs. C. How areyou? d. Mrs.H.,mynameisMrs.C.Illneedtoaskyouafewquestionsaboutwhathappened. NURSINGTB.COM ANS: D Addressthepersonbyusinghisorhersurname.Thenurseshouldintroducehimorherselfandgivethereason for the interview. Friendly small talk is not needed to buildrapport. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 7. Duringaninterview,thenursestates,Youmentionedhavingshortnessofbreath.Tellmemoreaboutthat. Which verbal skill is used with thisstatement? a. Reflection b. Facilitation c. Directquestion d. Open-endedquestion ANS:D Theopen-endedquestionasksfornarrativeinformation.Itstatesthetopictobediscussedbutonlyingeneral terms.Thenurseshoulduseittobegintheinterview,tointroduceanewsectionofquestions,andwheneverth person introduces a newtopic. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 8. Apatienthasfinishedgivingthenurseinformationaboutthereasonheisseekingcare.Whenreviewingthe 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 thesedata? a. Mr. Y., at your age, surely you have been hospitalizedbefore! b. Mr.Y.,IjustneedpermissiontogetyourmedicalrecordsfromCountyMedical. c. Mr.Y.,youmentionedthatyouhavebeenhospitalizedonseveraloccasions.Wouldyoutellme more aboutthat? d. Mr.Y.,Ijustneedtogetsomeadditionalinformationaboutyourpasthospitalizations.Whenwas the last time you were admitted for chestpain? ANS: D Thenurseshouldusedirectquestionsafterthepersonsopeningnarrativetofillinanydetailsheorsheleftout. The nurse also should use direct questions when specific facts are needed, such as when asking about past health problems or during the review ofsystems. DIF: Cognitive Level: Applying (Application) MSC:ClientNeeds:PsychosocialIntegrity NURSINGTB.COM 9. Inusingverbalresponsestoassistthepatientsnarrative,someresponsesfocusonthepatientsframeof referenceandsomefocusonthehealthcareprovidersperspective.Anexampleofaverbalresponsethat focuses on the health care providers perspective wouldbe: 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 patientsperspectivetotheperspectiveofthehealthcareprovider,andthehealthcareproviderstartstoexpress his or her own thoughts and feelings. Empathy, reflection, and facilitation responses focus on the patients frame ofreference. DIF:CognitiveLevel:Remembering(Knowledge) MSC: Client Needs: PsychosocialIntegrity 10. Whentakingahistoryfromanewlyadmittedpatient,thenursenoticesthatheoftenpausesandexpectantly looks at the nurse. What would be the nurses best response to this behavior? a. Be silent, and allow him to continue when he isready. b. Smileathimandsay,Dontworryaboutallofthis.Imsurewecanfindoutwhyyourehavingthese pains. c. Leanbackinthechairandask,Youarelookingatmekindoffunny;thereisntanythingwrong,is there? d. Standupandsay,Icanseethatthisinterviewisuncomfortableforyou.Wecancontinueitanother time. ANS: A Silentattentivenesscommunicatesthatthepersonhastimetothinkandtoorganizewhatheorshewishesto saywithoutaninterruptionfromthenurse.Healthprofessionalsmostofteninterruptthisthinkingsilence.The other responses are not conducive to idealcommunication. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 11. Awomanisdiscussingtheproblemssheishavingwithher2-year-oldson.Shesays,Hewontgotosleep atnight,andduringthedayhehasseveralfits.Igetsoupsetwhenthathappens.Thenursesbestverbal response would be: NURSINGTB.COM a. Go on, Imlistening. b. Fits? Tell me what you mean bythis. c. Yes, it can be upsetting when a child has afit. d. Dont be upset when he has a fit; every 2 year old hasfits. ANS: B Thenurseshoulduseclarificationwhenthepersonswordchoiceisambiguousorconfusing(e.g.,Tellmewhat youmeanbyfits.).Clarificationisalsousedtosummarizethepersonswordsortosimplifythewordstomake themclearer;thenurseshouldthenaskifheorsheisontherighttrack. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 12. A17-year-oldsinglemotherisdescribinghowdifficultitistoraisea3-year-oldchildbyherself.During thecourseoftheinterviewshestates,Icantbelievemyboyfriendleftmetodothisbymyself!Whataterrible thingtodotome!Whichoftheseresponsesbythenurseusesempathy? a. You feelalone. b. You cant believe he left youalone? c. It must be so hard to face this allalone. d. I would be angry, too; raising a child alone is nopicnic. 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,orsimplyplacingyourhandonthepersonsarm.Simplyreflectingthepersonswordsoragreeing with the person is not an empatheticresponse. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 13. A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco,anddruguse.Whenthenurseaskshimabouttobaccouse,hestates,Iquitsmokingaftermywifedied 7yearsago.However,thenursenoticesanopenpackofcigarettesinhisshirtpocket.Usingconfrontation,the nurse couldsay: a. Mr. K., I know that you arelying. b. Mr. K., come on, tell me how much yousmoke. NURSINGTB.COM c. Mr.K.,Ididntrealizeyourwifehaddied.Itmustbedifficultforyouatthistime.Pleasetellme more aboutthat. d. Mr.K.,youhavesaidthatyoudontsmoke,butIseethatyouhaveanopenpackofcigarettesin yourpocket. ANS: D Inthecaseofconfrontation,acertainaction,feeling,orstatementhasbeenobserved,andthenursenow focusesthepatientsattentiononit.Thenurseshouldgivehonestfeedbackaboutwhatisseenorfelt. Confrontationmayfocusonadiscrepancy,orthenursemayconfrontthepatientwhenpartsofthestoryare inconsistent. The other statements are notappropriate. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 14. Thenursehasusedinterpretationregardingapatientsstatementoractions.Afterusingthistechnique,it would be best for the nurseto: a. Apologize, because using interpretation can be demeaning for thepatient. b. Allow time for the patient to confirm or correct theinference. c. Continue with the interview as though nothing hashappened. d. Immediatelyrestatethenursesconclusiononthebasisofthepatientsnonverbalresponse. ANS: B Interpretation is not based on direct observation as is confrontation, but it is based on ones inference or conclusion.Thenurserisksmakingthewronginference.Ifthisisthecase,thenthepatientwillcorrectit. However,eveniftheinferenceiscorrect,interpretationhelpspromptfurtherdiscussionofthetopic. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 15. Duringaninterview,awomansays,IhavedecidedthatIcannolongerallowmychildrentolivewiththeir fathersviolence,butIjustcantseemtoleavehim.Usinginterpretation,thenursesbestresponsewouldbe: a. You are going to leavehim? b. If you are afraid for your children, then why cant youleave? c. Itsoundsasifyoumightbeafraidofhowyourhusbandwillrespond. d. Itsoundsasthoughyouhavemadeyourdecision.Ithinkitisagoodone. ANS: C NURSINGTB.COM This statement is not based on ones inference or conclusion. It links events, makes associations, or implies cause.Interpretationalsoascribesfeelingsandhelpsthepersonunderstandhisorherownfeelingsinrelation to the verbal message. The other statements do not reflectinterpretation. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 16. A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it soundsawful,butIreallydreadgoingintolabor.Thenurserespondsbystating,Oh,dontworryaboutlaborso much.Ihavebeenthroughit,andalthoughitispainful,manygoodmedicationsareavailabletodecreasethe pain.Whichstatementistrueregardingthisresponse?Thenursesreplywasa: a. Therapeuticresponse.Bysharingsomethingpersonal,thenursegiveshopetothiswoman. b. Nontherapeuticresponse.Byprovidingfalsereassurance,thenurseactuallycutofffurther discussion of the womansfears. c. Therapeuticresponse.Byprovidinginformationaboutthemedicationsavailable,thenurseis giving information to thewoman. d. Nontherapeuticresponse.Thenurseisessentiallygivingthemessagetothewomanthatlabor cannot be tolerated withoutmedication. ANS: B Byprovidingfalseassuranceorreassurance,thiscouragebuilderrelievesthewomansanxietyandgivesthe nurse the false sense of having provided comfort. However, for the woman, providing false assurance or reassuranceactuallyclosesoffcommunication,trivializesheranxiety,andeffectivelydeniesanyfurthertalk ofit. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity 17. Duringavisittotheclinic,apatientstates,ThedoctorjusttoldmehethoughtIoughttostopsmoking.He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case wouldbe: a. IdquitifIwereyou.Thedoctorreallyknowswhatheistalkingabout. b. Wouldyoulikesomeinformationaboutthedifferentwaysapersoncanquitsmoking? c. Stoppingyourdependenceoncigarettescanbeverydifficult.Iunderstandhowyoufeel. d. Whyareyouconfused?Didntthedoctorgiveyoutheinformationaboutthesmokingcessation program weoffer? ANS: B ClarificationshouldbeusedwhenthepersonsNwUoRrSdIcNhGoTicBe.CisOaMmbiguousorconfusing.Clarificationisalso usedtosummarizethepersonswordsortosimplifythewordstomakethemclearer;thenurseshouldthenask ifheorsheisontherighttrack.Theotherresponsesgiveunwantedadviceordonotofferahelpfulresponse. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 18. Asthenurseentersapatientsroom,thenursefindshercrying.Thepatientstatesthatshehasjustfoundout that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentlemanner: a. Youre afraid you might lose yourbreast? b. No, Im not sure what you are talkingabout. c. Illwaithereuntilyougetyourselfundercontrol,andthenwecantalk. d. Icanseethatyouareveryupset.Perhapsweshoulddiscussthislater. ANS: A Reflectionechoesthepatientswords,repeatingpartofwhatthepersonhasjustsaid.Reflectioncanalsohelp express the feelings behind a personswords. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 19. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the historyform,oneofthewrittenquestionsasks,Youdontsmoke,drink,ortakedrugs,doyou?Thisquestionis an exampleof: a. Talking toomuch. b. Usingconfrontation. c. Using biased or leadingquestions. d. Using blunt language to deal with distastefultopics. ANS:C This question is an example of using leading or biased questions. Asking, You dont smoke, do you? implies thatoneanswerisbetterthananother.Ifthepersonwantstopleasesomeone,thenheorsheiseitherforcedto answerinawaythatcorrespondstohisorherimpliedvaluesorismadetofeelguiltywhenadmittingtheother answer. DIF:CognitiveLevel:Understanding(Comprehension) MSC: Client Needs: PsychosocialIntegrity 20. Whenobservingapatientsverbalandnonverbalcommunication,thenursenoticesadiscrepancy.Which statementistrueregardingthissituation?TheNnUurRsSeIsNhGouTlBd.:COM a. Asksomeonewhoknowsthepatientwelltohelpinterpretthisdiscrepancy. b. Focusonthepatientsverbalmessage,andtrytoignorethenonverbalbehaviors. c. Trytointegratetheverbalandnonverbalmessagesandtheninterpretthemasanaverage. d. Focusonthepatientsnonverbalbehaviors,becausetheseareoftenmorereflectiveofapatients truefeelings. ANS: D When nonverbal and verbal messages are congruent, the verbal message is reinforced. When they are incongruent,thenonverbalmessagetendstobethetrueonebecauseitisunderlessconsciouscontrol.Thus studying the nonverbal messages of the patients and examiners and understanding their meanings are important. The other statements are nottrue. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PsychosocialIntegrity 21. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer beginstodiscusshissonstreatment,however,hesuddenlycrosseshisarmsagainsthischestandcrosseshis legs. This changed posture would suggest that the parentis: a. Simply changingpositions. b. More comfortable in thisposition. c. Tired and needs a break from theinterview. d. Uncomfortable talking about his sonstreatment. ANS: D Thepersonspositionisnoted.Anopenpositionwiththeextensionoflargemusclegroupsshowsrelaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tendstolookdefensiveandanxious.Anychangeinpostureshouldbenoted.Ifapersoninarelaxedposition suddenlytenses,thenthischangeinposturesuggestspossiblediscomfortwiththenewtopic. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity