Interview, Health History, General Survey, Vital Signs and Head to Toe

An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers:

A) posture.

B) mobility.

C) mood and affect.

D) physical deformity.

ANS: B) mobility

Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history.

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Which of these statements is true regarding the recording of data from the history and physical examination?

A) Use long, descriptive sentences to document findings.

B) Record the data as soon as possible after the interview and physical examination.

C) If the information is not documented, then it can be assumed that it was done as a standard of care.

D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.

ANS: B) Record the data as soon as possible after the interview and physical examination.

The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short clear phrases and should avoid redundant phrases and descriptions.

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Which of these is included in assessment of general appearance?

A) Height

B) Weight

C) Skin color

D) Vital signs

ANS: C) skin color

General appearance includes items such as level of consciousness, skin color, nutritional status, posture, mobility, facial expression, mood and affect, speech, hearing, and personal hygiene. Height, weight, and vital signs are considered measurements.

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Which statement regarding the recording of data from the history and physical examination is true?

a. Use long, descriptive sentences to document findings.

b. Record the data as soon as possible after the interview and physical examination.

c. If the information is not documented, then it can be assumed that it was done as a standard of care.

d. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.

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ANS: B

Data from the history and physical examination should be recorded as soon after the event

as possible. From a legal perspective, if it is not documented, then it was not done. Brief

notes should be taken during the examination. When documenting, the nurse should use

short, clear phrases and avoid redundant phrases and descriptions.

During assessment, the nurse notes an old vertical scar across the patient’s lower abdomen.

How should the nurse best document this finding?

a. With a full-scale drawing of patient and location of the scar

b. By using a comprehensive drawing to detail the type of scar

c. By using a line drawing of the abdomen with the location and length of the scar

d. With a detailed narrative description of how the scar was acquired

ANS: C

Simple line drawings should be used to describe the findings. A simple sketch of a tympanic membrane, breast, abdomen, or cervix should be drawn and the findings marked on it. The record should be kept complete but succinct by using short, clear phrases

The nurse is performing a general survey. The nurse:

a. Observes the patient’s body stature and nutritional status.

b. Interprets the subjective information the patient has reported.

c. Measures the patient’s temperature, pulse, respirations, and blood pressure.

d. Observes specific body systems while performing the physical assessment.

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ANS: A

The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behaviour.

When measuring a patient’s weight, the nurse will:

a. Weigh the patient wearing only undergarments.

b. Aim for similar daily weights regardless of type of scale used.

c. Allow the patient to keep the jacket and shoes on as long as these are documented

next to the weight.

d. Weigh the patient at the same time daily for a sequence of weights.

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ANS: D

A standardized balance or electronic standing scale is used to measure weight. The patient should remove his or her shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time

A patient takes weekly home blood pressure readings, with average reading being 126/82 mm Hg. The nurse recognizes that the patient:

a. Has hypertension.

b. Is normotensive.

c. Needs to increase exercise for weight loss.

d. Needs to decrease alcohol intake.

ANS: B

According to the Canadian Health Education Program (CHEP) recommendations a blood pressure under 135/85 mm Hg warrants continued follow-up, not a diagnosis of hypertension.

While examining a 7-year-old patient, the nurse uses physical growth as the best index of the child’s:

a. General health.

b. Genetic makeup.

c. Nutritional status.

d. Activity and exercise patterns.

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ANS: A

Physical growth is the best index of a child’s general health; recording the child’s height and weight helps determine normal growth patterns.

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

a. Increase in body weight from his younger years

b. Additional deposits of fat on the thighs and lower legs

c. Presence of kyphosis and flexion in the knees and hips

d. Change in overall body proportion, including a longer trunk and shorter extremities

ANS: C

Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

When assessing an older adult, which vital sign changes occur with aging?

a. Increase in pulse rate

b. Widened pulse pressure

c. Increase in body temperature

d. Decrease in diastolic blood pressure

ANS: B

With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse rate and temperature do not increase

The nurse measures the patient’s temperature to be 37.3°C during the afternoon. After comparing with the morning temperature of 36°C, the nurse:

a. Informs the physician that the patient has a temperature.

b. Recognizes that the patient’s emotions are influencing her temperature.

c. Documents the temperature as a normal finding.

d. Is concerned that the patient is too cold.

ANS: C

Normal temperature is influenced by the diurnal cycle, exercise, and age. A diurnal cyclecan influence temperature by 1°C to 1.5°C, with the trough occurring in the early morninghours and the peak in late afternoon to early evening.

When evaluating the temperature of older adults, the nurse knows that:

a. The body temperature of the older adult is lower than that of a younger adult.

b. An older adult’s body temperature is approximately the same as that of a young

child.

c. Body temperature depends on the type of thermometer used.

d. In the older adult, the body temperature varies widely because of less effective heat control mechanisms.

ANS: A

In older adults, the body temperature is usually lower than in other age groups, with a mean temperature of 36.2° C.

When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. The nurse:

a. Assumes that the patient is eager and interested in participating in the interview.

b. Evaluates the patient for abdominal pain, which may be exacerbated in the sitting position.

c. Assumes that the patient is having difficulty breathing and assists him to the supine position.

d. Recognizes that a tripod position is often used when a patient is having respiratory difficulties.

ANS: D

Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic obstructive pulmonary disease (COPD). The other actions or assumptions are not correct.

The nurse is taking temperatures in a clinic with a tympanic membrane thermometer (TMT).

Which statement is true regarding use of the TMT?

a. Taking tympanic temperature is more time consuming than taking rectal temperature.

b. The tympanic method is more invasive and uncomfortable than the oral method.

c. The risk for cross-contamination is reduced, compared with the rectal route.

d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

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ANS: C

The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient to use.

The chance of cross-contamination with the TMT is minimal because the ear canal is lined with skin, not mucous membranes

When assessing the radial pulse of a patient, the nurse will count the pulse for:

a. 1 minute, if the rhythm is irregular.

b. 15 seconds and then multiply by 4, if the rhythm is regular.

c. 2 full minutes to detect any variation in amplitude.

d. 10 seconds and then multiply by 6, if the patient has no history of cardiac abnormalities.

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ANS: A

Recent research suggests that the 30-second interval multiplied by 2 is the most accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full minute

When assessing a patient’s pulse, the nurse will also assess:

a. Force.

b. Pallor.

c. Capillary refill time.

d. Timing in the cardiac cycle.

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ANS: A

The pulse is assessed for rate, rhythm, and force

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse’s next action would be to:

a. Immediately notify the physician.

b. Consider this finding normal in children and young adults.

c. Check the child’s blood pressure and note any variation with respiration.

d. Document that this child has bradycardia and continue with the assessment.

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ANS: B

Sinus arrhythmia is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration.

When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:

a. Is usually recorded on a 0-2–point scale.

b. Demonstrates elasticity of the vessel wall.

c. Is a reflection of the heart’s stroke volume.

d. Reflects the blood volume in the arteries during diastole.

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ANS: C

The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.

A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” The nurse’s best reply is:

a. “The numbers are within the normal range, and there is nothing to worry about.”

b. “The bottom number is the diastolic pressure and reflects the stroke volume of the

heart.”

c. “The top number is the systolic blood pressure and reflects the pressure of the

blood against the arteries when the heart contracts.”

d. “The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure.”

ANS: C

The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient’s question and use terms he can understand

While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as _________________, help determine blood pressure.

a. Pulse rate

b. Pulse pressure

c. Vascular output

d. Peripheral vascular resistance

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ANS: D

The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls

A nurse is helping at a health fair at the local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that:

a. After menopause, blood pressure readings in women are usually lower than those in men.

b. The blood pressure of an adult of African descent is usually higher than that of an adult of European descent and of the same age.

c. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight.

d. A teenager’s blood pressure reading will be lower than that of an adult.

ANS: B

In Canada, adults of African descent usually have a higher blood pressure compared with those of European descent and of the same age. The incidence of hypertension is twice as high among those of African descent; reasons for the difference are not fully understood, but it appears to be a result of genetic and environmental factors. After menopause, blood pressure in women is higher than in men; blood pressure measurements in people who are obese are usually higher than in those who are not overweight. Normally, a gradual rise occurs through childhood and into the adult years

The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:

a. Yield a falsely low blood pressure.

b. Yield a falsely high blood pressure.

c. Be the same, regardless of cuff size.

d. Vary as a result of the technique of the person performing the assessment.

ANS: B

Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery.

A student is late for his appointment and has rushed across campus to the health clinic. The nurse should:

a. Allow 5 minutes for him to relax and rest before checking his vital signs.

b. Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise.

c. Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences.

d. Check blood pressure with the student in the supine position, which will allow him to relax and will help obtain a more accurate reading.

ANS: A

When a person is comfortable and relaxed, a valid blood pressure can be obtained. Many people are anxious at the beginning of an examination; the nurse should allow at least a 5-minute rest period before measuring blood pressure

The nurse will perform palpation before auscultating blood pressure. The reason for this is to:

a. More clearly hear Korotkoff’s sounds.

b. Detect the presence of an auscultatory gap.

c. Avoid missing a falsely elevated blood pressure.

d. More readily identify phase IV of Korotkoff’s sounds.

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ANS: B

Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when Korotkoff’s sounds disappear during auscultation.

The nurse has collected the following information on a patient: palpated blood pressure—180 mm Hg; auscultated blood pressure—170/100 mm Hg; apical pulse—60 beats per minute; radial pulse—70 beats per minute. What is the patient’s pulse pressure?

a. 10 mm Hg

b. 70 mm Hg

c. 80 mm Hg

d. 100 mm Hg

ANS: B

Pulse pressure is the difference between systolic and diastolic blood pressure (170 – 100 = 70 mm Hg) and reflects the stroke volume.

When auscultating the blood pressure of a 25-year-old patient, the nurse notices that phase I Korotkoff’s sounds begin at 200 mm Hg. At 100 mm Hg, Korotkoff’s sounds are muffled. At 92 mm Hg, Korotkoff’s sounds disappear. How should the nurse record this patient’s blood pressure?

a. 200/92 mm Hg

b. 200/100 mm Hg

c. 100/200/92 mm Hg

d. 200/100/92 mm Hg

ANS: A

In adults, the last audible sound best indicates the diastolic pressure. When a variance is greater than 10 to 12 mm Hg between phases IV and V, both phases should be recorded along with the systolic reading (e.g., 142/98/80 mm Hg).

A patient is seen in the clinic for complaints of “fainting episodes that started last week.”

How should the nurse proceed with the examination?

a. Blood pressure readings are taken in both the arms and the thighs.

b. The patient is assisted to the lying position, and his blood pressure is taken.

c. His blood pressure is recorded in the lying, sitting, and standing positions.

d. His blood pressure is recorded in the lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.

ANS: C

If the person is known to have hypertension, is taking antihypertensive medications, or reports a history of fainting or syncope, then the blood pressure reading should be taken in three positions: lying, sitting, and standing.

A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

a. These readings are a normal response and attributable to changes in the patient’s position.

b. The change in blood pressure readings is called orthostatic hypotension.

c. The blood pressure reading in the lying position is within normal limits.

d. The change in blood pressure readings is considered within normal limits for the patient’s age.

ANS: B

Orthostatic hypotension is a greater than 20 mm Hg drop in systolic pressure, which occurs with a quick change to the standing position. Older persons have the greatest risk for this problem.

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?

a. The pulse is more difficult to palpate because of the stiffness of the blood vessels.

b. An increased respiratory rate and a shallower inspiratory phase are expected findings.

c. A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures.

d. Changes in the body’s temperature regulatory mechanism are more likely to cause fever to develop in the older person.

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ANS: B

Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respiratory rate. An increase in the rigidity of the arterial walls makes the pulse actually easier to palpate. Pulse pressure is widened in older adults, and changes in the body temperature regulatory mechanism render the older person less likely to have fever but at a greater risk for hypothermia

The nurse is performing a general survey of a patient. Which finding is considered normal?

a. When standing, the patient’s base is narrow.

b. The patient appears older than his stated age.

c. Arm span (fingertip to fingertip) is greater than the height.

d. Arm span (fingertip to fingertip) equals the patient’s height.

ANS: D

When performing the general survey, the patient’s arm span (fingertip to fingertip) should equal the patient’s height. An arm span that is greater than the person’s height may indicate Marfan’s syndrome. The base should be wide when the patient is standing, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism

What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

a. Diastolic blood pressure may not be heard.

b. Diastolic blood pressure may be falsely low.

c. Systolic blood pressure may be falsely low.

d. Systolic blood pressure may be falsely high.

ANS: C

If an auscultatory gap is undetected, then a falsely low systolic or falsely high diastolic reading may result, and this is common in patients with hypertension

When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement?

a. MAP is the pressure of the arterial pulse.

b. MAP reflects the stroke volume of the heart.

c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.

d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

ANS: C

MAP is the pressure that forces blood into tissues, averaged over the cardiac cycle. Stroke volume is reflected by the blood pressure. MAP is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer; rather, it is a value closer to diastolic pressure plus one-third of the pulse pressure

A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?

a. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.

b. The patient should be directed to walk around the room and his blood pressure assessed after this activity.

c. Blood pressure and pulse are assessed at the beginning and at the end of the examination.

d. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.

ANS: A

Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions

Which of these specific measurements is the best index of a child’s general health?

a. Vital signs

b. Height and weight

c. Head circumference

d. Chest circumference

ANS: B

Physical growth, measured by height and weight, is the best index of a child’s general health

The nurse is counting an infant’s respirations. Which technique is correct?

a. Watching the chest rise and fall

b. Watching the abdomen for movement

c. Placing a hand across the infant’s chest

d. Using a stethoscope to listen to the breath sounds

ANS: B

Watching the abdomen for movement is the correct technique because the infant’s respirations are normally more diaphragmatic than thoracic. The other responses do not reflect correct techniques.

When checking for proper blood pressure cuff size, which guideline is correct?

a. The standard cuff size is appropriate for all sizes

b. The length of the rubber bladder should equal 80% of the arm circumference.

c. The width of the rubber bladder should equal 80% of the arm circumference.

d. The width of the rubber bladder should equal 40% of the arm circumference.

ANS: D

The width of the rubber bladder should equal 40% of the circumference of the person’s arm.

The length of the bladder should equal 80% of this circumference

While measuring a patient’s blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? **(Select all that apply.)**

a. The person supports his or her own arm during the blood pressure reading.

b. The blood pressure cuff is too narrow for the extremity.

c. The arm is held at the level of the heart.

d. The cuff is loosely wrapped around the arm.

e. The person is sitting with his or her legs crossed.

f. The nurse does not inflate the cuff high enough.

ANS: A, B, D, E

Several factors can result in blood pressure readings that are falsely high or low. Most of the options will result in falsely high readings. Not inflating the cuff high enough or poor inflation of the cuff result in a falsely low systolic. Having the patient’s arm held at the level of the heart is one part of the correct technique.

(Refer to Table 10-3, Common Errors in Blood Pressure Measurement.)

1\. For which of the following patients would a comprehensive health history be appropriate?

A) A new patient with the chief complaint of “I sprained my ankle”

B) An established patient with the chief complaint of “I have an upper respiratory infection”

C) A new patient with the chief complaint of “I am here to establish care”

D) A new patient with the chief complaint of “I cut my hand”

Ans: C

Feedback: This patient is here to establish care, and because she is new to you, a comprehensive health history is appropriate

The components of the health history include all of the following except which one?

A) Review of systems

B) Thorax and lungs

C) Present illness

D) Personal and social items

B

Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and relieved by rest.

A) Subjective

B) Objective

A

Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120.

A) Subjective

B) Objective

B

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? The woman is:

a. Excited about her pregnancy but nervous about the labour

b. Exhibiting verbal and nonverbal behaviours 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 respond to her negatively if she states this

ANS: B

Communication involves all behaviours—conscious and unconscious, verbal and nonverbal. All behaviours have meaning. Her behaviour does not imply that she is nervous about labour, upset by her husband, or worried about the nurse’s response. The nurse needs to further explore the behaviour through the use of open-ended questions.

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

a. Well-adjusted adolescent, who came in for a sports physical

b. Recovering alcoholic, who came in for a basic physical examination

c. Man whose wife has just been diagnosed with lung cancer

d. Man with a hearing impairment, who uses sign 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?

a. Reduces noise by turning off televisions and radios

b. Reduces the distance between the interviewer and the patient to 1 m or less

c. Provides a dim light that makes the room cozy and helps the patient relax

d. Arranges seating across a desk or table to allow the patient some personal space

ANS: A

The nurse should reduce noise by turning off the television, radio, and other unnecessary equipment because multiple stimuli will be confusing to the patient. The interviewer and patient should be approximately 1.5 m apart; the room should be well lit, enabling the interviewer and the patient to see each other clearly. Having a table or desk between the two parties 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 memory later. Which statement regarding note taking is true?

a. Note taking may impede the nurse’s observation of the patient’s nonverbal behaviours.

b. Note taking allows the patient to continue at his or her 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. It breaks eye contact too often and shifts the attention away from the patient, which diminishes his or her sense of importance. Note taking may also interrupt the patient’s narrative flow, and it impedes the observation of the patient’s nonverbal behaviour

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

a. Summary

b. Closing

c. Body

d. Opening or introduction

ANS: D

When gathering a complete history, the nurse should give the reason for the interview during the opening or introduction phase of the interview, not during or at the end of the interview.

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 Carol.”

b. “Hello, Mrs. Smith, my name is Carol; I am one of the nurses working here. It sure is cold today!”

c. “Mrs. Smith my name is Carol. How are you?”

d. “Hello, Mrs. Smith. My name is Carol. I am a nurse, and I need to ask you a few questions about what happened.”

ANS: D

Address the person by using his or her surname. The nurse should introduce himself or herself and role, and give the reason for the interview. Friendly small talk is not needed to build rapport

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

a. “Mr. Y., at your age, surely you have been hospitalized before!”

b. “Mr. Y., I just need permission to get your medical records from County Medical.”

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.

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

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

b. Smile at him, and say, “Don’t worry about all of this. I’m sure we can find out why you’re having these pains.”

c. Lean back in the chair, and say, “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

Silent attentiveness communicates that the person has time to think and to organize what he or she wishes to say without an interruption from the nurse. Health care professionals most often interrupt this thinking silence. The other responses are not conducive to ideal communication

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

a. “Go on, I’m listening.”

b. “Fits? Tell me what you mean by this.”

c. “Yes, it can be upsetting when a child has a fit.”

d. “Don’t be upset when he has a fit; every 2-year-old has fits.”

ANS: B

The nurse should use clarification when the person’s word choice is ambiguous or confusing (e.g., “Tell me what you mean by fits.”). Clarification is also used to summarize the person’s words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track.

A 17-year-old woman, who is a lone parent, is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview, she states, “I can’t believe my boyfriend left me to do this by myself! What a terrible thing to do to me!” Which of these responses by the nurse uses empathy?

a. “You feel alone.”

b. “You can’t believe he left you alone?”

c. “It must be so hard to face this all alone.”

d. “I would be angry, too; raising a child alone is no picnic.”

ANS: C

An empathetic response recognizes the feeling and puts it into words. It names the feeling, allows its expression, and strengthens rapport. Other empathetic responses are: “This must be very hard for you”; “I understand”; or simply placing your hand on the person’s arm. Simply reflecting the person’s words or agreeing with the person is not an empathetic response

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 clarification, the nurse could say:

a. “Mr. K., I know that you are lying.”

b. “Mr. K., come on, tell me how much you smoke.”

c. “Mr. K., I didn’t realize your wife had died. It must be difficult for you at this time. Please tell me more about that.”

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

ANS: D

In the case of clarification, a certain action, feeling, or statement has been observed, and the nurse now focuses the patient’s attention on it. The nurse should give honest feedback about what is seen or felt. Clarification may focus on a discrepancy, or the nurse may ask for clarification from the patient when parts of the story are inconsistent. The other statements are not appropriate

The nurse has used interpretation regarding a patient’s statement or actions. After using this technique, it would be best for the nurse to:

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

Interpretation is not based on direct observation as is confrontation, but it is based on one’s inference or conclusion. The nurse risks making the wrong inference. If this is the case, then the patient will correct it. However, even if the inference is correct, interpretation helps prompt further discussion of the topic.

During an interview, a woman says, “I have decided that I can no longer allow my children to live with their father’s violence, but I just don’t seem to be able to leave him.” Using interpretation, the nurse’s best response would be:

a. “You are going to leave him?”

b. “If you are afraid for your children, then why can’t you leave?”

c. “It sounds as if you might be afraid of how your husband will respond.”

d. “It sounds as though you have made your decision. I think it is a good one.”

ANS: C

This statement is not based on one’s inference or conclusion. It links events, makes associations, or implies cause. Interpretation also ascribes feelings and helps the person understand his or her own feelings in relation to the verbal message. The other statements do not reflect interpretation

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

a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman.

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

c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman.

d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labour cannot be tolerated without medication.

ANS: B

By providing false assurance or false reassurance, this courage builder relieves the woman’s anxiety and gives the nurse the false sense of having provided comfort. However, for the woman, providing false assurance or false reassurance actually closes off communication, trivializes her anxiety, and effectively denies any further talk of it

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 nurse’s most appropriate response in this case would be:

a. “I’d quit if I were you. The doctor really knows what he is talking about.”

b. “Would you like some information about the different ways a person can quit smoking?”

c. “Stopping your dependence on cigarettes can be very difficult. I understand how you feel.”

d. “Why are you confused? Didn’t the doctor give you the information about the smoking cessation program we offer?”

ANS: B

Clarification should be used when the person’s word choice is ambiguous or confusing. 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. The other responses give unwanted advice or do not offer a helpful response

As the nurse enters a patient’s 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 nurse’s most therapeutic response would be to say in a gentle manner:

a. “You’re afraid you might lose your breast?”

b. “No, I’m not sure what you are talking about.”

c. “I’ll wait here until you get yourself under control, and then we can talk.”

d. “I can see that you are very upset. Perhaps we should discuss this later.”

ANS: A

Reflection echoes the patient’s words, repeating part of what the person has just said.

Reflection can also help express the feelings behind a person’s words

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

a. Talking too much

b. Using confrontation

c. Using biased or leading questions

d. Using blunt language to deal with distasteful topics

ANS: C

This question is an example of using leading or biased questions. Asking, “You don’t smoke, do you?” implies that one answer is better than another. If the person wants to please someone, then he or she is either forced to answer in a way that corresponds to his or her implied values or is made to feel guilty when admitting the other answer

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

a. Ask someone who knows the patient well to help interpret this discrepancy

b. Focus on the patient’s verbal message and try to ignore the nonverbal behaviours

c. Try to integrate the verbal and nonverbal messages and then interpret them as an average

d. Focus on the patient’s nonverbal behaviours because these are often more reflective of a patient’s true feelings

ANS: D

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When nonverbal and verbal messages are congruent, the verbal message is reinforced. When they are incongruent, the nonverbal message tends to be the true one because it is under less conscious control. Thus studying the nonverbal messages of the patients and examiners and understanding their meanings are important. The other statements are not true.

During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss the son’s treatment, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:

a. Simply changing posture

b. More comfortable in this position

c. Tired and needs a break from the interview

d. Uncomfortable talking about his son’s treatment

ANS: D

The person’s posture should be noted. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to make the person look defensive and anxious. Any change in posture should be noted as well. If a person in a relaxed position suddenly tenses, then this change in posture suggests possible discomfort with the new topic

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?

a. Tickle the toddler, and get her to laugh.

b. Get down to her eye level, and ask her about the toy she is holding.

c. Continue to ignore her until it is time for the physical examination.

d. Ask the mother to leave during the examination of the toddler because toddlers often fuss less if the parent is not in view.

ANS: B

Although most of the communication is with the parent, the nurse should not completely ignore the child. Making contact will help ease the toddler later during the physical examination. The nurse should begin by asking about the toys the child is playing with or about a special doll or teddy bear brought from home. “Does your doll have a name?” or “What can your truck do?” Get down to the child’s eye level

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

a. Tell the child that the blood pressure cuff is going to give her arm a big hug

b. Tell the child that the blood pressure cuff is asleep and cannot wake up

c. Give the blood pressure cuff a name and refer to it by this name during the assessment

d. Tell the child that by using the blood pressure cuff, it will be possible to see how strong the heart is pumping blood through the body

ANS: D

Take the time to give a short, simple explanation with a concrete explanation for any unfamiliar equipment that will be used on the child. Preschoolers are animistic; they imagine inanimate objects can come alive and have human characteristics, for example, that a bloodpressure cuff can wake up and bite or pinch

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

a. An aged person has a longer story to tell.

b. An aged person is usually lonely and likes to have someone to talk to.

c. Aged persons lose much of their mental abilities and require longer time to complete an interview.

d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said.

ANS: A

The interview usually takes longer with older adults because they have a longer story to tell. It is not necessarily true that all older adults are lonely, have lost mental abilities, or are hard of hearing

During her prenatal checkup, the patient begins to cry as the nurse asks her about previous pregnancies. The patient states that she is remembering her last pregnancy, which had ended in a miscarriage. The nurse’s best response to her crying would be:

a. “I’m so sorry for making you cry!”

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

c. “Why don’t I step out for a few minutes until you’re feeling better?”

d. “I can see that you feel sad about this; why don’t we talk about something else?”

ANS: B

A beginning examiner usually feels horrified when the patient starts crying. When the nurse says something that “makes the person cry,” the nurse should not think he or she has hurt the person. The nurse has, in fact, hit on an important topic and should not move to a new topic.

The nurse should allow the person to cry and to express his or her feelings fully. The nurse can offer a tissue and wait until the crying subsides to resume talking.

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

a. The nurse should try to relax; these behaviours are culturally appropriate for this person.

b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview.

c. Such behaviour is indicative of sexual aggression, and the nurse should confront this person about it.

d. The nurse should laugh but say that he or she is uncomfortable with the person’s proximity and ask him to move away.

ANS: A

Both the patient’s and the nurse’s sense of spatial distance are significant throughout the interview and physical examination, and culturally appropriate zones vary widely. Some cultural groups value physical proximity and may perceive a health care provider who is distancing himself or herself as being aloof and unfriendly

A female Métis patient has come to the clinic for follow-up diabetes teaching. During the interview, the nurse notices that the patient never makes eye contact and speaks mostly looking at the floor. Which statement is true regarding this situation?

a. The woman is nervous and embarrassed.

b. She has something to hide and is ashamed.

c. The woman is showing inconsistent verbal and nonverbal behaviours.

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

ANS: D

Eye contact is perhaps among the most culturally variable nonverbal behaviours. Asian, Indigenous, Indochinese, Arabian, and Appalachian people may consider direct eye contact impolite or aggressive, and they may avert their eyes during the interview. Indigenous peoples often do not maintain eye contact during the interview, which is a culturally appropriate behaviour, indicating that the listener is paying close attention to the speaker

The nurse is performing a health interview with a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?

a. “Do you take medicines?”

b. “Do you sterilize the bottles?”

c. “Do you have nausea and vomiting?”

d. “You have been taking your medicine, haven’t you?”

ANS: A

In a situation during which a language barrier exists and no interpreter is available, simple words should be used, avoiding medical jargon. The use of contractions and pronouns should also be avoided. Nouns should be repeatedly used, and one topic at a time should be discussed. A combination of verbal and nonverbal communication would be most beneficial in such situations.

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?

a. “How is your family?”

b. “How is your job?”

c. “Tell me about your hypertension.”

d. “How has your health been since your last visit?”

ANS: D

Open-ended questions are used for gathering narrative information. This type of questioning should be used to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic

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 nurse’s comment?

a. This comment is inappropriate because it shows the nurse’s bias.

b. This comment is appropriate because members of the health care team are experts in their area of patient care.

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

d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.

ANS: C

Using authority responses promotes dependency and inferiority. Avoiding the use of authority is best. Although the health care provider and the patient do not have equal professional knowledge, both have equally worthy roles in the health care process. The other statements are not correct.

A female patient does not speak English fluently, and the nurse needs to choose an interpreter.

Which of the following would be the most appropriate choice?

a. Trained interpreter

b. Male family member

c. Female family member

d. Volunteer college student from the foreign language studies department

ANS: A

Whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and a person of the same gender as the patient’s is preferred, when possible.

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?

a. This question may place the patient on the defensive.

b. This question is an innocent search for information.

c. Discussing his behaviour with his wife would have been better.

d. A direct question is the best way to discover the reasons for his behaviour

ANS: A

An adult’s use of “why” questions usually implies blame and condemnation and places the person on the defensive. The other statements are not correct

During the interview portion of data collection, the nurse collects __________ data.

a. Physical

b. Historical

c. Objective

d. Subjective

ANS: D

The interview is the first, and really the most important, part of data collection. During the interview, the nurse collects subjective data, that is, what the person says about himself or herself

The nurse is conducting an interview. Which of these statements regarding open-ended questions is true? **(Select all that apply.)**

a. Open-ended questions elicit cold facts.

b. They allow for self-expression.

c. Open-ended questions build and enhance rapport.

d. They leave interactions neutral.

e. Open-ended questions call for short one- to two-word answers.

f. They are used when narrative information is needed.

ANS: B, C, F

Open-ended questions allow for self-expression, build and enhance rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?

a. To provide an opportunity for interaction between the patient and the nurse

b. To provide a form for obtaining the patient’s biographic information

c. To document the normal and abnormal findings of a physical assessment

d. To provide a database of subjective information about the patient’s past and current health

ANS: D

The purpose of the health history is to collect subjective data—what the person says about himself or herself. The other options are not correct

When the nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient:

a. Has a history of drug abuse and therefore is not reliable.

b. Provided consistent information and therefore is reliable.

c. Smiled throughout interview and therefore is assumed reliable.

d. Would not answer questions concerning stress and therefore is not reliable.

ANS: B

A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct

A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the past 24 hours. How would the nurse best document his reason for seeking care?

a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis.

b. J.M. came into the clinic complaining of having black stools for the past 24 hours.

c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked.

d. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours.

ANS: D

The reason for seeking care is a brief spontaneous statement in the person’s own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. The symptom description is enclosed in quotation marks to indicate the person’s exact words

A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response?

a. “Can you point to where it hurts?”

b. “We’ll talk more about that later in the interview.”

c. “What have you had to eat in the past 24 hours?”

d. “Have you ever had any surgeries on your abdomen?”

ANS: A

A final summary of any symptom the person has should include, along with seven other critical characteristics, “Location: Be specific.” The person is asked to point to the location

A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’s statement?

a. “How does your family react to your pain?”

b. “The pain must be terrible. You probably pinched a nerve.”

c. “I’ve had back pain myself, and it can be excruciating.”

d. “How would you say the pain affects your ability to do your daily activities?”

ANS: D

The symptom of pain is difficult to quantify because of individual interpretation. With pain, adjectives should be avoided, and the patient should be asked how the pain affects his or her daily activities. The other responses are not appropriate

In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?

a. Patient denies usual childhood illnesses.

b. Patient states he was a “very healthy” child.

c. Patient states his sister had measles, but he did not.

d. Patient denies having had measles, mumps, rubella, chickenpox, pertussis, and strep throat.

ANS: D

Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat.

Avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles)

A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information?

a. “Are you allergic to any other drugs?”

b. “How often have you received penicillin?”

c. “I’ll write your allergy on your chart so you won’t receive any penicillin.”

d. “Describe what happens to you when you take penicillin.”

ANS: D

Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic reaction.

The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:

a. Emphysema

b. Head trauma

c. Mental illness

d. Fractured bones

ANS: C

Questions asked should specifically enquire about family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis

Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin?

a. Skin appears dry.

b. No lesions are obvious.

c. Patient denies any colour change.

d. Lesion is noted on the lateral aspect of the right arm.

ANS: C

The history should be limited to patient statements or subjective data—factors that the person says were or were not present

The nurse is obtaining the history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?

a. “Do you perform testicular self-examinations?”

b. “Have you ever noticed any pain in your testicles?”

c. “Have you had any problems with passing urine?”

d. “Do you have any history of sexually transmitted diseases?”

ANS: A

Health promotion activities for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues

In response to a question about stress, a 39-year-old woman tells the nurse that her husband and her mother both died in the past year. Which response by the nurse is most appropriate?

a. “This has been a difficult year for you.”

b. “I don’t know how anyone could handle that much stress in 1 year!”

c. “What did you do to cope with the loss of both your husband and your mother?”

d. “That is a lot of stress; now let’s go on to the next section of your history.”

ANS: C

Questions about coping and stress management include questions regarding the kinds of stresses in one’s life, especially in the past year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful

In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?

a. This information is necessary to determine the patient’s reliability.

b. Alcohol can interact with all medications and can make some diseases worse.

c. The nurse needs to be able to teach the patient about the dangers of alcohol use.

d. This information is not necessary unless a drinking problem is obvious.

ANS: B

Alcohol adversely interacts with all medications and is a factor in many social problems, such as child abuse or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore assessing for signs of hazardous alcohol use is important. The other options are not correct

The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response?

a. “Maybe she is just teething.”

b. “I will check her ear for an ear infection.”

c. “Are you sure she is really having pain?”

d. “Describe what she is doing to indicate she is having pain.”

ANS: D

With a very young child, the parent is asked, “How do you know the child is in pain?” A young child pulling at his or her ears should alert parents to the child’s ear pain. Statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.

The nurse is obtaining the health history of an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?

a. Obstetric history

b. Childhood illnesses

c. General health for the past 20 years

d. Current health promotion activities

ANS: D

It is important for the nurse to recognize positive health measures, such as what the person has been doing to help himself or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age

A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be:

a. “Can you tell me what they look like?”

b. “Don’t worry about it. You are only taking two medications.”

c. “How long have you been taking each of the pills?”

d. “Would you have a family member bring in your medications?”

ANS: D

The person may not know the name or purpose of a drug. When this occurs, ask the person or a family member to bring in the drug to be identified. The other responses would not help identify the medications

The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?

a. “Do you wear glasses?”

b. “Are you able to dress yourself?”

c. “Do you have any thyroid problems?”

d. “How many times a day do you have a bowel movement?”

ANS: B

Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that he or she can or cannot perform. The other responses do not relate to functional assessment.

The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?

a. “Please stay during the interview; you can answer for her if she does not know the answer.”

b. “It would help to interview the three of you together.”

c. “While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?”

d. “While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”

ANS: D

The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires

The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? **(Select all that apply.)**

a. “Where is the headache pain?”

b. “Did you have these headaches as a child?”

c. “On a scale of 1 to 10, how bad is the pain?”

d. “How often do the headaches occur?”

e. “What makes the headaches feel better?”

f. “Do you have any family history of headaches?”

ANS: A, C, D, E

The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed:

(1) P: provocative or palliative;

(2) Q: quality or quantity;

(3) R: region or radiation;

(4) S: severity scale;

(5) T: timing; and

(6) U: understand the patient’s perception.

Asking, “Where is the pain?” reflects “region.” Asking the patient to rate the pain on a 1 to 10 scale reflects “severity.” Asking “How often…” reflects “timing.” Asking what makes the pain better reflects “provocative.” The other options reflect health history and family history

The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? (Select all that apply.)

a. “How much junk food does your child eat?”

b. “How many teeth has he lost, and when did he lose them?”

c. “Is he able to tie his shoelaces?”

d. “Does he take children’s vitamins?”

e. “Can he tell time?”

f. “Does he have any food allergies?”

ANS: B, C, E

Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history

When assessing a patient’s general appearance, the nurse should include which question?

a. Is the patient’s muscle strength equal in both arms?

b. Is ptosis or facial droop present?

c. Does the patient respond appropriately to questions?

d. Are the pupils equal in reaction and size?

ANS: C

Assessing whether the patient responds appropriately to questions is a component of an assessment of the patient’s general appearance. The other answers reflect components of the neurological examination

During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is:

A) warts.

B) bullae.

C) freckles.

D) papules.

ANS: C) freckles

A macule is solely a lesion with color change, flat and circumscribed, less than 1 cm. Macules are also known as freckles.

See Chapter 12. Pages: 203-250

During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences:

A) vertigo.

B) tinnitus.

C) syncope.

D) dizziness.

ANS: A) vertigo

Vertigo is the sensation of moving around in space (subjective) or of having objects move about the person (objective) and is a result of a disturbance of equilibratory apparatus.

See Chapter 23. Pages: 621-678

The nurse should wear gloves for which of these examinations?

A) Measuring vital signs

B) Palpation of the sinuses

C) Palpation of the mouth and tongue

D) Inspection of the eye with an ophthalmoscope

ANS: C) Palpation of the mouth and tongue

Gloves should be worn when the examiner is exposed to the patient's body fluids.

Page: 766

Which of these statements is true regarding the complete physical assessment?

A) The male genitalia should be examined in the supine position.

B) The patient should be in the sitting position for examination of the head and neck.

C) The vital signs, height, and weight should be obtained at the end of the examination.

D) To promote consistency between patients, the examiner should not vary the order of the assessment.

ANS: B) The patient should be in the sitting position for examination of the head and neck.

The head and neck should be examined in the sitting position to best palpate the thyroid and lymph nodes. The male patient should stand during examination of the genitalia. Vital signs are measured early in the assessment. The sequence of the assessment may need to vary according to different patient situations.

Page: 764

A 5-year old child is in the clinic for a checkup. The nurse would expect him to:

A) have to be held on his mother's lap.

B) be able to sit on the examination table.

C) be able to stand on the floor for the examination.

D) be able to remain alone in the examination room

ANS: B) be able to sit on the examination table.

At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parent's lap.

Pages: 777-778

After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first:

A) empty the bladder.

B) completely disrobe.

C) lie on the examination table.

D) walk around the room.

ANS: A) empty the bladder

Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table.

Page: 764