TEST BANK
Advanced Health Assessment and Diagnostic Reasoning
Jacqueline Rhoad
4th Edition
JN
U
R
SE
,Table of Contents
Part I – Strategies for Effective Health Assessment
1. Interview and History-Taking Strategies
2. Physical Examination Strategies
3. Documentation Strategies
4. Cultural and Spiritual Assessment
5. Nutritional Assessment
Part II – Advanced Assessment of Systemic Disorders
6. Mental Health Disorders
JN
7. Integumentary Disorders
8. Eye Disorders
9. Ear Disorders
U
10. Nose, Sinus, Mouth, and Throat Disorders
11. Respiratory Disorders
R
12. Cardiovascular Disorders
13. Endocrine Disorders
SE
14. Gastrointestinal Disorders
15. Neurological Disorders
16. Male Genitourinary Disorders
17. Female Genitourinary and Breast Disorders
18. Musculoskeletal Disorders
,Chapter 1: Interview and History Taking Strategies
MULTIPLE CHOICE
• 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:
Excited about her pregnancy but nervous
a.
about the labor.
Exhibiting verbal and nonverbal behaviors
b.
that do not match.
Excited about her pregnancy, but her husband
c.
is not and this is upsetting to her.
JN
Not excited about her pregnancy but believes
d. the nurse will negatively respond to her if she
states this.
ANS: B
U
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
R
nurses response.
• Receiving is a part of the communication process.
Which receiver is most likely to misinterpret a
SE
message sent by a health care professional?
Well-adjusted adolescent who came in for a
a.
sports physical
Recovering alcoholic who came in for a basic
b.
physical examination
Man whose wife has just been diagnosed with
c.
lung cancer
Man with a hearing impairment who uses sign
d. language to communicate and who has an
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.
• The nurse makes which adjustment in the physical environment
to promote the success of an interview?
Reduces noise by turning off televisions and
a.
radios
Reduces the distance between the interviewer
b.
and the patient to 2 feet or less
Provides a dim light that makes the room
c.
cozy and helps the patient relax
Arranges seating across a desk or table to
d.
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
JN
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.
• In an interview, the nurse may find it necessary to take notes to
aid his or her memory later. Which statement is trueregarding
U
note-taking?
Note-taking may impede the nurses
a. observation of the patients nonverbal
R
behaviors.
Note-taking allows the patient to continue at
his or her own pace as the nurse records what
SE
b.
is said.
Note-taking allows the nurse to shift attention
c. away from the patient, resulting in an
increased comfort level.
Note-taking allows the nurse to break eye
d. contact with the patient, which may
increase his 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 patients narrative flow, and it impedes the
observation of the patients nonverbal behavior.
• 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
Advanced Health Assessment and Diagnostic Reasoning
Jacqueline Rhoad
4th Edition
JN
U
R
SE
,Table of Contents
Part I – Strategies for Effective Health Assessment
1. Interview and History-Taking Strategies
2. Physical Examination Strategies
3. Documentation Strategies
4. Cultural and Spiritual Assessment
5. Nutritional Assessment
Part II – Advanced Assessment of Systemic Disorders
6. Mental Health Disorders
JN
7. Integumentary Disorders
8. Eye Disorders
9. Ear Disorders
U
10. Nose, Sinus, Mouth, and Throat Disorders
11. Respiratory Disorders
R
12. Cardiovascular Disorders
13. Endocrine Disorders
SE
14. Gastrointestinal Disorders
15. Neurological Disorders
16. Male Genitourinary Disorders
17. Female Genitourinary and Breast Disorders
18. Musculoskeletal Disorders
,Chapter 1: Interview and History Taking Strategies
MULTIPLE CHOICE
• 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:
Excited about her pregnancy but nervous
a.
about the labor.
Exhibiting verbal and nonverbal behaviors
b.
that do not match.
Excited about her pregnancy, but her husband
c.
is not and this is upsetting to her.
JN
Not excited about her pregnancy but believes
d. the nurse will negatively respond to her if she
states this.
ANS: B
U
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
R
nurses response.
• Receiving is a part of the communication process.
Which receiver is most likely to misinterpret a
SE
message sent by a health care professional?
Well-adjusted adolescent who came in for a
a.
sports physical
Recovering alcoholic who came in for a basic
b.
physical examination
Man whose wife has just been diagnosed with
c.
lung cancer
Man with a hearing impairment who uses sign
d. language to communicate and who has an
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.
• The nurse makes which adjustment in the physical environment
to promote the success of an interview?
Reduces noise by turning off televisions and
a.
radios
Reduces the distance between the interviewer
b.
and the patient to 2 feet or less
Provides a dim light that makes the room
c.
cozy and helps the patient relax
Arranges seating across a desk or table to
d.
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
JN
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.
• In an interview, the nurse may find it necessary to take notes to
aid his or her memory later. Which statement is trueregarding
U
note-taking?
Note-taking may impede the nurses
a. observation of the patients nonverbal
R
behaviors.
Note-taking allows the patient to continue at
his or her own pace as the nurse records what
SE
b.
is said.
Note-taking allows the nurse to shift attention
c. away from the patient, resulting in an
increased comfort level.
Note-taking allows the nurse to break eye
d. contact with the patient, which may
increase his 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 patients narrative flow, and it impedes the
observation of the patients nonverbal behavior.
• 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
