Chapter 3 Physical assessment

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 known to be most accurate? The woman is:

Exhibiting verbal and nonverbal behaviors that do not match

Recieving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?

Man whose wife has just been diagnosed with lung cancer

The nurse makes which adjustment in the physical environments to promote the success of an interview?

Reduces noise by turning off televisions and radios

In a interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?

Note-taking may impede the nurses observation of the patients nonverbal behaviors

The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the ___ phase of the interview process.

Opening or introduction

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some informations from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?

Mrs. H, my name is Mrs. C, I will need to ask you a few questions about what happened

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?

Open ended question

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be the most appropriate to gather these date?

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?

In using verbal responses to assist the patients narrative, some responses focus on the patients frame of references and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be:

Confrontation

When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior?

Be silent, and allow him to continue when he is ready

A woman is discussing the problems she is having with her 2 year old son. She says, he won’t go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be?

Fits? Tell me what you mean by this.

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 this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy?

It must be so hard to face this all alone

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, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:

Mr. K you hav said that you don’t smoke, but I see that you have an open pack of cigarettes in your pocket

The nurse has used interpretation regarding a patients statement or actions. After using this technique it would be best for the nurse to

Allow time for the patient to confirm or correct the inference

During an interview a woman says, I have decided that I can no longer allow May children o live with their fathers violence but I just can’t seem to leave him. Using interpretation, the nurse best response would be:

It sounds as if you might be afraid of how your husband will respond

A pregnante woman states, I just know labor will be so painful that I won’t be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh don’t worry about labor so much. I have through it and although it is painful many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was?

Non therapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears

During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesn’t understand how hard I’ve tried. I just don’t know the best way to do it. What should I do? The nurses most appropriate response in this case would be?

would you like some information about the different ways a person can quit smoking?

As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, I’m so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner:

you’re afraid you might lose your breast?

A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, of the written questions asks, you don’t smoke, drink, or take drugs, do you? This question is an example of?

Using biased or leading questions

When observing a patients verbal and nonverbal communication, the nurse notices discrepancy. Which statement is true regarding this situation? The nurse should?

Focus on the patients nonverbal behaviors because there are often more reflective of a patients true feelings

During an interview a parent of a hospitalized child I sitting in an open position. As the interviewer begins to discuss his sons treatment however her suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is?

Uncomfortable talking about his sons treatment

A mother brings her 28 month old daughter into the clinic for a well child visit. At the beginning of the visit the nurse focuses attention away from the toddler, but as the interview progresses the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?

Stoop down to her level, and her about the toy she is holding

During an examination of a 3 year old child the nurse will need to take her blood pressure. What might the nurse do to try to gain the child’s full cooperation?

Tell the child that by using the blood pressure cuff, we can see how strong her muscles are

A 16 year old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him?

Be totally honestly with him, even if the information is unpleasant

A 75 year old woman is at the office for a pre operative interview. The nurse is aware that interview may take longer than interview with younger persons. What is the reason for this?

An aged person has a longer story to tell

The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?

Determine the communication method he prefers

During a prenatal check a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be?

I can see that you are sad remembering this. It is all right to cry

A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forwards and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next?

The nurse should try to relax; these behaviors are culturally appropriate for this person

A female American Indian has come to the clinic for a follow up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation?

She is showing that she is carefully listening to what the nurse is saying

the nurse is preforming a health interview on a patient who has a language barrier, and now interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?

Do you take medicine?

A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. which question or statement by the nurse is most appropriate when beginning the interview?

How has your health been since your last visit?

The nurse makes this comment to a patient I know it may be hard but you should do what the doctor ordered because she is the expert in this field. which statement is correct about the nurses comment?

this type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation

A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?

Trained interpreter

During a follow up visit the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, why haven’t you taken your insulin? Which statement is an appropriate evaluation of this question?

This question may place the patient on the defensive

The nurse is nearing the end of an interview. Which statement is appropriate at this time?

Is there anything else you would like to mention?

During the interview position of data collection, the nurse collects ___ data

Subjective

During an interview the nurse would expect that most of the interview will take place at what distance?

Social distance

A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overly sexual comment. The nurses best reaction would be?

It makes me uncomfortable when you talk that way. Please stop.