Test Bank for Physical Examination and Health Assessment 9th Edition By Carolyn Jarvis; Ann L. Eckhardt. WITH100%CORRECT AND VERIFIED ANSWERS. LATEST 2024 UPDATE, GUARANTEED A+ GRADE.

Complete Test bank, All Chapters are included. For more Test banks, ATI, HESI exams, and more contact us.     Chapter 01: Evidence-Based Assessment Jarvis: Physical Examination and Health Assessment, 9th 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. What type of assessment data is this? a. Objective b. Reflective c. Subjective d. Introspective ANS: A Objective data is 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) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type of assessment data is this? a. Objective b. Reflective c. Subjective d. Introspective ANS: C Subjective data is what the person says about him or herself during history taking. Objective data is 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) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. What do the patient’s record, laboratory studies, objective data, and subjective data combine to form? a. Database b. Admitting data c. Financial statement d. Discharge summary ANS: A The objective and subjective data together with the patient’s record and laboratory studies, form the database. The other items are not part of the patient’s record, laboratory studies, or data. DIF: Cognitive Level: Remembering (Knowledge) 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. Which action would the nurse take next? a. Notify the patient’s physician. b. Document the sound exactly as it was heard. c. Validate the data by asking another nurse 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 by either repeating the assessment themselves or asking another nurse to assess the breath sounds. If the nurse has less experience analyzing breath sounds, then he or she should ask an expert to listen. When unsure of a sound heard while listening to a patient’s breath sounds, the nurse should validate the data before documenting to ensure accuracy and before notifying the patient’s physician. To validate that data, the nurse either repeats the assessment himself or herself or asks another nurse to assess the breath sounds. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. The nurse is conducting a class for new graduate nurses. While teaching the class, what would the nurse keep in mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are more likely to base their decisions on? 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 to make decisions. It takes time, perhaps a few years, in similar clinical situations to achieve competency and it is functioning at the level of an expert practitioner when intuition is included in making clinical decisions. While information in journal articles and advice from supervisors may assist in making decisions, novice nurses do not typically base their decisions on them. It would also be important that if information from journal articles and advice from supervisors were used, that they were evidence based. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 6. 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. EBP does not consider the patient’s own preferences as important. ANS: C EBP is a systematic approach to practice that emphasizes the use of research evidence in combination with the clinician’s expertise and clinical knowledge (physical assessment), as well as patient values and preferences, 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: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 7. 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). Postoperative pain, diabetic teaching for a patient newly diagnosed with diabetes, and a small laceration on sole of the foot are not considered first-level priority problems. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. 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 Abnormal laboratory values are a second-level priority problem. 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). Low self-esteem and lack of knowledge are considered third-level priority as although they are important to a patient’s health, they can be addressed after more urgent health problems are addressed. Severely abnormal vital signs would be considered a first-level priority problem. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. 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 involves clustering, or grouping together, assessment data that appear to be associated, or related, and helps the nurse see relationships among the data. Identifying gaps is looking for missing information and validation involves ensuring accuracy, and distinguishing relevant and irrelevant data involves identifying data the fit, or support the problem, but none of those help the nurse to see relationships. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. 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 planning, implementation, and evaluation ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, planning, implementation, and evaluation. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. 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 (e.g., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security), and then third-level problems (those that are important to the patient’s health but can be attended to after more urgent health problems are addressed). DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. Which is a barrier to incorporating EBP? 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. Lack of significant research studies, insufficient clinical skills of nurses, and inadequate physical assessment skills are not barriers to incorporating EBP. Instead, 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 which are barriers to incorporating EBP. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 13. During a staff meeting, nurses discuss the problems with identifying evidence-based practices to incorporate 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. Teach the nurses how to conduct research. d. Ensuring time for staff to review current literature. ANS: D Facilitating support for EBP at the organizational level includes ensuring time for staff to review current literature; establishing a nursing research committee; holding EBP classes for interested staff; and ensuring access to resources. Forming a committee or teaching nurses to actually conduct research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. Just posting published research studies on the unit’s bulletin board does not facilitate EBP, as not all published research is valid or pertinent to the nurses’ practice. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. 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 and functioning as a whole within the environment. The basis of disease originates from both the external environment and from within the person; the individual human is an open system, continually changing and adapting; and each person is responsible for his or her own personal health state (not the nurse). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. The nurse is performing a physical assessment on a newly admitted patient. Which is an example of objective information obtained during the physical assessment? 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 is 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. A patient’s history of allergies, use of medications at home, and date of last menstrual periods are all subjective data. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 16. A visiting nurse is making an initial home visit for a patient who has several chronic medical problems. Which type of database is most appropriate to collect in this setting? a. A follow-up database b. A focused database c. A complete database d. An emergency database ANS: C A complete database is collected in primary care settings, 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. A follow-up database is performed to follow up, or evaluate changes, on short-term and chronic health problems, but would be collected at appropriate intervals after a complete database was collected at the initial visit. A focused database is conducted for a limited or short-term problem, not for a patient with several chronic problems. An emergency database is an urgent, rapid collection of data often compiled concurrently while lifesaving measures are being performed. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 17. In which situation is it most appropriate for the nurse to perform 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 a scheduled surgery. d. Patient in an outpatient clinic has cold and influenza-like symptoms. ANS: D In a focused or problem-centered database, the nurse collects a “mini” database, which is smaller in scope than the complete database. This mini database primarily concerns one problem, one cue complex, or one body system. A complete database should be conducted for a patient being admitted to a long-term care facility or being admitted for a scheduled surgery. An emergency database should be conducted for a patient with sudden and severe shortness of breath. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood pressure checks since changing medications 2 months ago. Which is the most appropriate action for the nurse to take? a. Collect a follow-up database and then check the patient’s blood pressure. b. Ask the patient to read her health record and indicate any changes since her last visit. c. Check the patient’s blood pressure. d. Obtain a complete health history on the patient before checking her blood pressure. ANS: A A follow-up database is used in all settings to follow up on short-term or chronic health problems. The other responses are not appropriate for the situation. Asking the patient to read her health history and indicate any changes since her last visit is not appropriate. Just checking the patient’s blood pressure without following up on or assessing for any changes in the patient’s condition is inappropriate. It is not necessary to conduct a complete health history as one was conducted 2 months ago. Rather a follow-up assessment regarding the patient’s blood pressure and factors associated with it are necessary. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. A patient is brought by ambulance to the emergency department with multiple injuries received in an automobile accident. The patient is alert and cooperative, but their injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first then perform the physical examination and institute lifesaving measures. b. Simultaneously ask history questions while performing the examination and initiating lifesaving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform lifesaving measures and delay asking any history questions until the patient is transferred to the intensive care unit. ANS: B The emergency database calls for a rapid collection of data, often concurrently compiled with lifesaving measures. The other responses are not appropriate for the situation. This is an emergency situation and an emergency database with rapid collection of the data compiled concurrently with lifesaving measures. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 20. Which statement best describes a proficient nurse? 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. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient. ANS: D The proficient nurse, with more time and experience than the novice nurse, is able to understand 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. A nurse that has little experience with a specified population and uses rules to guide performance is a novice nurse. A nurse that has an intuitive grasp of a clinical situation and quickly identifies the accurate solution is an expert nurse. Seeing actions in the context of daily plans for patients describes competency or a competent nurse. DIF: Cognitive Level: Understanding (Comprehension) 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 helps 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. Hypoactive bowel sounds and +2 edema of the left hand are separate cues that do not relate to the other cues. The other cues (wheezes, cough, report of dyspnea, respiration rate and rhythm) all relate to the patient’s respiratory status. The cues of bowel sounds and peripheral edema are not related to the respiratory cues. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care OTHER 1. Put the following patient situations in order of the level of priority (from highest priority to lowest priority). 1. First-level priority problem 2. Second-level priority problem 3. Third-level priority problem a. A teenager who was stung by a bee during a soccer match is having trouble breathing. b. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. c. An older adult with a urinary tract infection is also showing signs of confusion and agitation. ANS: A, C, B 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. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care   Chapter 02: Cultural Assessment Jarvis: Physical Examination and Health Assessment, 9th Edition MULTIPLE CHOICE 1. The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one’s culture? a. Learned through language acquisition and socialization b. Genetically determined on the basis of racial background c. A nonspecific phenomenon and is adaptive but unnecessary d. Biologically determined on the basis of physical characteristics ANS: A Culture is a complex phenomenon that includes attitude, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It is not biologically or genetically determined. It is learned by the individual. It is a universal phenomenon and is important because a person’s culture defines health and illness, identifies when treatment is needed and which treatment is acceptable, and informs a person of how symptoms are expressed and which symptoms are important. DIF: Cognitive Level: Understanding (Comprehension) 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 the characteristics of culture? a. Static and unchanging b. Members share similar physical characteristics. c. Members share a common geographic origin and religion. d. Adapted to specific conditions related to environmental and technical factors ANS: D Culture has four basic characteristics, one of which is that it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. The other three characteristics are: (1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the cultural group; and (3) dynamic and ever changing. Culture is not static and unchanging but is dynamic and ever changing. Members of a culture do not necessarily share similar physical characteristics. Sharing similar physical characteristics refers to race. Members of a culture do not necessarily share a common geographic origin and religion. Sharing a common geographic origin and religion refers to ethnicity. DIF: Cognitive Level: Analyzing (Analysis) 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, customs, and skills acquired by members of a society” reflects which term? a. Norms b. Culture c. Ethnicity d. Assimilation ANS: B The culture that develops in any given society is unique, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit the given definition. Norms refers to the typical or usual. Ethnicity refers to a social group that may possess shared traits, such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Assimilation refers to taking on the characteristics of the dominant culture. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity 4. The nurse is discussing the term subculture with a student nurse. Which statement by the nurse would best describe subculture? a. “Fitting as many people as possible into the majority culture.” b. “Identifying 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.” d. “Recognizing groups of people within a culture with shared characteristics that are not common to all members of the 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. Fitting as many people as possible into the majority culture identifying small groups of people who do not want to be identified with the larger culture, and singling out groups of people who suffer differential and unequal treatment as a result of cultural variations do not describe a subculture. A subculture is a group of people with a culture that share some different beliefs, values, or attitudes than the majority of the larger culture. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that which is the largest and fastest growing population? a. Asian b. Hispanic c. American Indian d. African American/black ANS: B Hispanics are the largest and fastest growing population in the United States, followed by African Americans/blacks, Asians, two or more races, American Indians and Alaska natives, and other groups. DIF: Cognitive Level: Remembering (Knowledge) 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 their 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 small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from “evil spirits.” When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet’s meaning to the patient. Asking the patient to lock the item with other valuables in the hospital’s safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient’s cultural health practices. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 7. 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.” c. “Ethnicity pertains to a social group that may possess shared traits such as religion and language.” d. “Ethnicity is learned from birth through the processes of language acquisition and socialization.” ANS: C Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and 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. 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. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 8. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one’s spirituality? a. Belief in and the worship of God or gods b. Being closely tied to one’s ethnic background c. Attendance at a specific church or place of worship d. A connection with something larger than oneself and belief in transcendence ANS: D Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Belief in and the worship of God or gods and attendance at a specific church or place of worship apply to religion. Being closely tied to one’s ethnic background is not a concept of spirituality or religion. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 9. 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. Integration b. Assimilation c. Biculturalism d. Heritage consistency ANS: B Assimilation is a unidirectional, linear process moving from unacculturated to acculturated in which a person develops a new cultural identity and becomes like members of the dominant culture. Integration and biculturalism are bidirectional and bidimensional inducing reciprocal change in both cultures and maintain in aspects of the original culture in one’s ethnic identity. There is nothing in the question to indicate that she has maintained aspects of her original culture and states that her family and friends would hardly recognize her. Nothing in the questions refers to aspects of heritage consistency, or the degree to which she has retained her original/traditional culture. DIF: Cognitive Level: Understanding ( comprehension) MSC: Client Needs: Psychosocial Integrity 10. The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. “Do you smoke?” b. “What is your religion?” c. “Do you have a history of heart disease?” d. “How many years have you lived in the United States?” ANS: D Asking questions about a person’s country of ancestry, years in the United States, etc. allows 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) MSC: Client Needs: Psychosocial Integrity 11. 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) MSC: Client Needs: Psychosocial Integrity 12. An Asian-American woman is experiencing diarrhea, which is believed to be “cold” or “yin.” What should the nurse recognize that the woman may likely try to treat it? 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 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) MSC: Client Needs: Psychosocial Integrity 13. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects this philosophy’s view of “health”? 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. According to the yin/yang theory, health is believed to exist when all aspects of the person are in perfect balance. Being able to work and produce; being happy, stable, and feeling good; and caring for others and functioning socially do not demonstrate a balance in all aspects of a person. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 14. The statement that illness is caused by an imbalance or disharmony in the forces of nature most accurately reflects the views about illness from which theory? a. Germ theory b. Naturalistic theory c. Magicoreligious theory d. Biomedical or scientific theory ANS: B The naturalistic perspective states that the forces of nature must be kept in natural balance or harmony. An imbalance in the forces of nature can cause illness. The other options are not correct. The germ theory is similar to biomedical theory, both of which believe that illness or disease is caused by microorganisms. The magicoreligious theory believes that illness is caused by supernatural forces such as God or other supernatural powers. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 15. What does an individual who believes the magicoreligious theory of illness and disease believe is the cause of illness? a. Germs and viruses b. Supernatural forces c. Eating imbalanced (hot/cold) foods d. 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. Germs and viruses refer to the biomedical theory. Eating imbalanced hot or cold food is applicable to the yin/yang naturalist theory. Imbalance within one’s spiritual nature is not considered a cause of illness in any of the theories of illness. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 16. What should the nurse, who is caring for an American Indian woman seeking help to regulate her diabetes, anticipate or expect of the patient? a. Will comply with the treatment prescribed. b. Has 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 In addition to seeking help from you as a biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Members of the American Indian culture often seek the care of a shaman or medicine man in addition to help from Western medicine. Some, 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). Oftentimes patients of a different culture, especially if there is a language barrier, do not comply with prescribed treatments. Seeking the care of a biomedical or scientific health care provider does not mean the patient has given up her belief in naturalistic causes of disease as they often seek the care of folk healing to complement the biomedical treatment. American Indians typically believe the naturalistic view of illness, not the magicoreligious theory, so the nurse should not anticipate that the patient is having a crisis of faith. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 17. During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality? a. “Is a personal search to discover a supreme being.” b. “Is an organized system of beliefs concerning the cause, nature, and purpose of the universe.” c. “Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife.” d. “Focuses on a connection with something bigger than oneself and a belief in transcendence.” ANS: D Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence. It 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. Searching to discover a supreme being; an organized system of beliefs concerning the cause, nature, and purpose of the universe; and believing that each person exists forever in some form all refer to religion rather than spirituality. Spirituality is a broader term focused on a connection with something bigger than oneself and a belief in transcendence. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 18. When caring for children with a different cultural perspective, what would the nurse recognize may pose a challenge? 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. d. Parents are often the decision makers, and they have no knowledge of their children’s 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. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 19. 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.” What is this woman likely 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: Applying (Application) MSC: Client Needs: Psychosocial Integrity 20. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment? 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-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments such as over-the-counter medications are effective. Self-treatment is not always less expensive. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 21. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence the humors of the body. b. Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual. d. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to 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. Herbs, medicines, spiritual connectedness, and social aspects of the individual are not any of the four humors in the hot/cold theory. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 22. 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 and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication such as “What cultural or spiritual beliefs are important to you.” Asking if they are of the Christian faith does not promote open communication. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. Asking how often they seek help from a medical provider is not pertinent to a cultural assessment. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 23. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? a. Trying prayer before seeking medical help b. Believing that illness is a punishment of sin 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) MSC: Client Needs: Psychosocial Integrity 24. The nurse should recognize that categories such as ethnicity, gender, and religion illustrate which concept? 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. Ethnicity, gender, and religion are not concepts of family, cultures, or spirituality. Instead they are concepts of subcultures which are groups of people within a larger culture that share differences in ethnicity, religion, education, occupation, age, and gender from the larger culture. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 25. The nurse is reviewing concepts related to one’s heritage and beliefs. Which concept refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe? a. Culture b. Religion c. Ethnicity d. Spirituality ANS: B Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services (Victor & Treschuk, 2020). Religion is a shared experience of spirituality or the values, beliefs, and practices into which people either are born or that they may adopt to meet their personal spiritual needs through communal actions, such as religious affiliation; attendance and participation in a religious institution, prayer, or meditation; and religious practices Culture is a complex phenomenon that includes attitude, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It does not refer to a belief in a divine or superhuman power. 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. Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity 26. When planning a cultural assessment, the nurse should include which component? a. Family history b. Chief complaint c. Medical history d. Health practices ANS: D Health practices are one component of a cultural assessment. The other items reflect other aspects of the patient’s history. Family history, chief complaint, and medical history are part of a patient’s history but not part of a cultural assessment. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. 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. “How do you describe illness?” 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. Questions regarding family history and surgeries are not part of a patient’s health beliefs, but are part of the patient’s physical history. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity   Chapter 03: The Interview Jarvis: Physical Examination and Health Assessment, 9th Edition MULTIPLE CHOICE 1. The nurse is conducting an interview with a woman who has recently learned that she is pregnant and 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 when describing this woman? 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. d. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this. ANS: B Communication is all behaviors, conscious and unconscious, verbal and nonverbal. All behaviors have meaning. Her verbal communication demonstrates excitement about the pregnancy but her nonverbal behavior (looking nervously at her hands and sighing loudly) often indicates anxiety. 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: Applying (Application) 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 who came in with his wife who was just diagnosed with lung cancer d. Man with a hearing impairment who has an interpreter with him who came in for a follow-up blood pressure check ANS: C In addition to a receiver interpreting a sender’s message based on their past experiences, culture, and self-concept, physical and emotional states also play a role in interpretation. The man whose wife has just been diagnosed with lung cancer may be experiencing emotions that affect his receiving. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 3. Which adjustment in the physical environment would the nurse make to promote the success of an interview? a. Arrange seating across a desk or table. b. Reduce noise by turning off televisions and radios. c. Reduce the distance between the interviewer and the patient to 2 feet or less. d. Provide dim lighting to make the room cozy and help the patient relax. ANS: B The nurse should secure a quiet environment, thus, 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. Sitting closer than 4 to 5 feet from a patient, or encroaching on them, can cause anxiety. The room should be well-lit, enabling the interviewer and patient to see each other clearly. DIF: Cognitive Level: Applying (Application) 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. b. Note-taking allows the patient to continue at their own pace as the nurse records what is said. c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d. Note-taking allows the nurse to break eye 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, one of which is impeding the nurse’s observations of the patient’s nonverbal behavior. Note-taking often interrupts the patient’s narrative flow, rather than allowing them to keep their own pace. Note-taking can break eye contact and also shift the nurse’s attention away from the patient which can diminish the patient’s sense of importance. DIF: Cognitive Level: Understanding (Comprehension) 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.” Based on this question, the nurse is at which phase of the interview process? a. Summary b. Closing c. Working 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) MSC: Client Needs: Health Promotion and Maintenance 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 Nurse C.” b. “Mrs. H., my name is Nurse C. How are you?” c. “Hello, Mrs. H., my name is Nurse C. It sure is cold today!” d. “Mrs. H., my name is Nurse C. I’ll need to ask you a few questions about what happened.” ANS: D The nurse should address the person by using his or her surname as automatic use of the first name is too familiar for most adults and lessens dignity. The nurse should introduce him or herself and give the reason for the interview. Friendly small talk is not needed to build rapport. Statements such as “How are you today” and “It sure is cold out today” are small talk and are not necessary to build rapport. DIF: Cognitive Level: Applying (Application) 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 Open-ended questions ask for narrative information and give the patient free rein. They state the topic to be discussed but only in general terms, which is what the statement in this question does. The nurse should use open-ended questions to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. Reflection and facilitation refer to the nurse’s (interviewer’s) verbal response of their reactions to the facts or feeling the patient has communicated. Direct questions elicit a one or two word answer such as yes or no. The statement in this question is eliciting more than a yes or no response, so it is not a direct question. Instead the statement in the question is an open-end question allowing the patient free rein on what to say. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 8. A patient has finished giving the nurse information about the reason for 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 this 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.” c. “Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?” d. “Mr. Y., I just need to get some additional information about your past hospitalizations. 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. The nurse should not assume that a patient has been hospitalized based on their age and stating such is inappropriate. Getting the patient’s medical records from another facility is not necessary during the interview process. Asking the patient to tell you more about hospitalization in order to complete missing interview data is not necessary; instead, direct questions should be asked when specific facts are needed. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 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. Which type of verbal response focuses on the health care provider’s perspective? 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. Confrontation focuses on the health care provider’s frame of reference and involves the health care provider expressing his or her own thoughts and feelings. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity 10. When taking a history from a newly admitted patient, the nurse notices that the patient often pauses and expectantly looks at the nurse. What would be the nurse’s best response to this behavior? a. Lean forward slightly and making eye contact ask “Is there anything else?” b. Smile at him and say, “Don’t worry about all of this. I’m sure we can get to the bottom of your symptoms.” c. Lean back in the chair and ask, “You are looking at me kind of funny; there isn’t anything wrong, is there?” d. Stand up and say, “I can see that this interview is uncomfortable for you. We can continue it another time.” ANS: A Typically patients will answer questions with short answers and then pause and look to the health care provider for direction on whether to continue. In this case, the health care provider should lean forward slightly, make eye contact, and look interested and if the patient does not continue, then ask them to tell you more or ask if there anything else. The other responses are not conducive to ideal communication. Leaning back in the chair or standing up indicates disinterest or closure and making statements such as “Don’t worry about all of this. I’m sure we can get to the bottom of your symptoms;” “You are looking at me kind of funny; there isn’t anything wrong, is there?”; or “I can see that this interview is uncomfortable for you. We can continue it another time” dismiss the patient’s feelings or are confrontational and are not conducive to ideal communication. DIF: Cognitive Level: Applying (Application) 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.” Which is the best response by the nurse to gain a better understanding of the problem? 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. Telling the woman “Go on, I’m listening”; “Yes, it can be upsetting when a child has a fit”; or “Don’t be upset when he has a fit; every 2 year old has fits” does not allow the nurse to clarify what the woman means by the term “fits” which is necessary to gain a better understanding of the problem. DIF: Cognitive Level: Applying (Application) 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 care for a child 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. Some 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 is not an empathetic response. Simply reflecting the person’s words by saying “You feel alone” or “You can’t believe he left you alone”, or agreeing with the person by saying “I would be angry, too; raising a child alone is no picnic” are not empathetic responses. They do not name the feeling, allow its expression or strengthen rapport. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity 13. The nurse has used interpretation regarding a patient’s statement or actions. What should the nurse do after using this technique? a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurse’s conclusion on the basis of the patient’s nonverbal response. ANS: B The nurse’s, or interviewer’s, interpretation of a patient’s statement is based on their inference or conclusion. The nurse risks making the wrong inference. Pausing after an interpretation allows time for the patient to correct it if it is wrong. Even if the inference is correct, interpretation helps prompt further discussion of the topic. Apologizing after interpreting a patient’s statement should not be necessary as the nurse should have stated that the interpretation is just his or her own interference from what the patient said and not a conclusion and is open for clarification. Continuing the interview as if nothing has happened or immediately restating the nurse’s conclusion based on the patient’s nonve