Chapter 1
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. These types of data would be:
a. Objective.
b. Reflecti
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Chapter 1
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. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Objective data are 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.
2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Subjective data are what the person says about him or herself during history taking. Objective data are 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.
3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
Together with the patient’s record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patient’s record, laboratory studies, or data.
4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to:
a. Immediately notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present.
When unsure of a sound heard while listening to a patient’s breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct.
7. 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. The patient’s own preferences are not important with EBP.
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists.
8. 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
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) (see Table 1-1).
9. 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
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) (see Table 1-1).
10. 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
Clustering related cues helps the nurse see relationships among the data.
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions.
12. 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 identification, planning, implementation, and evaluation
The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
13. 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
First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems.
14. Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis.
15. Barriers to incorporating EBP include:
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.
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.
16. What step of the nursing process includes data collection by health history, physical examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2).
17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making 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. Encourage the nurses to visit the library to review studies.
d. Teach the nurses how to conduct electronic searches for research studies.
Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research.
18. 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.
Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state.
19. The nurse recognizes that the concept of prevention in describing health is essential because:
a. Disease can be prevented by treating the external environment.
b. The majority of deaths among Americans under age 65 years are not preventable.
c. Prevention places the emphasis on the link between health and personal behavior.
d. The means to prevention is through treatment provided by primary health care practitioners.
A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior.
20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
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.
Objective data are 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.
21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?
a. A follow-up data base to evaluate changes at appropriate intervals
b. An episodic data base because of the continuing, complex medical problems of this patient
c. A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health
d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly
The complete data base is collected in a primary care setting, 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.
22. Which situation is most appropriate during which the nurse performs 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 surgery the following day.
d. Patient in an outpatient clinic has cold and influenza-like symptoms.
In a focused or problem-centered data base, the nurse collects a “mini” data base, which is smaller in scope than the completed data base. This mini data base primarily concerns one problem, one cue complex, or one body system.
23. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
a. Collect a follow-up data base and then check her blood pressure.
b. Ask her to read her health record and indicate any changes since her last visit.
c. Check only her blood pressure because her complete health history was documented 2 months ago.
d. Obtain a complete health history before checking her blood pressure because much of her history information may have changed.
A follow-up data base is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation.
24. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
a. Collect history information first, then perform the physical examination and institute life-saving measures.
b. Simultaneously ask history questions while performing the examination and initiating life-saving measures.
c. Collect all information on the history form, including social support patterns, strengths, and coping patterns.
d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.
The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation.
25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:
a. Identify the cause of his illness.
b. Make accurate disease diagnoses.
c. Provide cultural health rights for the individual.
d. Provide culturally sensitive and appropriate care.
The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care.
26. In the health promotion model, the focus of the health professional includes:
a. Changing the patient’s perceptions of disease.
b. Identifying biomedical model interventions.
c. Identifying negative health acts of the consumer.
d. Helping the consumer choose a healthier lifestyle.
In the health promotion model, the focus of the health professional is on helping the consumer choose a healthier lifestyle.
27. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individual’s condition, and compare actual outcomes with expected outcomes.
d. Interpret data, and then identify clusters of cues and make inferences.
Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse evaluates the individual’s condition and compares the actual outcomes with expected outcomes (See Figure 1-2).
28. Which statement best describes a proficient nurse? A proficient nurse is one who:
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.
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.
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
Clustering related cues help 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.
MATCHING
Put the following patient situations in order according to the level of priority.
a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
b. A teenager who was stung by a bee during a soccer match is having trouble breathing.
c. An older adult with a urinary tract infection is also showing signs of confusion and agitation.
1. a = First-level priority problem
2. b = Second-level priority problem
3. c = Third-level priority problem
Chapter 2
1. The nurse is reviewing the development of culture. Which statement is correct regarding the development of one’s culture? Culture is:
a. Genetically determined on the basis of racial background.
b. Learned through language acquisition and socialization.
c. A nonspecific phenomenon and is adaptive but unnecessary.
d. Biologically determined on the basis of physical characteristics.
Culture is learned from birth through language acquisition and socialization. It is not biologically or genetically determined and is learned by the individual.
2. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics?
a. Cultures are static and unchanging, despite changes around them.
b. Cultures are never specific, which makes them hard to identify.
c. Culture is most clearly reflected in a person’s language and behavior.
d. Culture adapts to specific environmental factors and available natural resources.
Culture has four basic characteristics. Culture adapts to specific conditions related to environmental and technical factors and to the availability of natural resources, and it is dynamic and ever changing. Culture is learned from birth through the process of language acquisition and socialization, but it is not most clearly reflected in one’s language and behavior.
3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating “the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society” reflects which term?
a. Mores
b. Norms
c. Culture
d. Social learning
The culture that develops in any given society is always specific and distinctive, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit the given definition.
4. When discussing the use of the term subculture, the nurse recognizes that it is best described as:
a. Fitting as many people into the majority culture as possible.
b. Defining 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. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
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.
5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is:
a. Hispanic.
b. Black.
c. Asian.
d. American Indian.
Hispanics are the largest and fastest growing population in the United States, followed by Asians, Blacks, American Indians and Alaska natives, and other groups.
6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his 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.
The nurse should inquire about the amulet’s meaning. Amulets, such as charms, are often considered an important means of protection from “evil spirits” by some cultures.
7. The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? “The caregiver:
a. Is able to speak the patient’s native language.”
b. Possesses some basic knowledge of the patient’s cultural background.”
c. Applies the proper background knowledge of a patient’s cultural background to provide the best possible health care.”
d. Understands and attends to the total context of the patient’s situation.”
Culturally competent implies that the caregiver understands and attends to the total context of the individual’s situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. It does not require the caregiver to speak the patient’s native language.
8. The nurse recognizes that an example of a person who is heritage consistent would be a:
a. Woman who has adapted her clothing to the clothing style of her new country.
b. Woman who follows the traditions that her mother followed regarding meals.
c. Man who is not sure of his ancestor’s country of origin.
d. Child who is not able to speak his parents’ native language.
Someone who is heritage consistent lives a lifestyle that reflects his or her traditional heritage, not the norms and customs of the new country.
9. 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 within the social system that claims shared values and traditions.”
d. “Ethnicity is learned from birth through the processes of language acquisition and socialization.”
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. 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.
10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of one’s spirituality?
a. Belief in and the worship of God or gods
b. Attendance at a specific church or place of worship
c. Personal effort made to find purpose and meaning in life
d. Being closely tied to one’s ethnic background
Spirituality refers to each person’s unique life experiences and his or her personal effort to find purpose and meaning in life. The other responses apply to religion.
11. 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. Assimilation
b. Heritage consistency
c. Biculturalism
d. Acculturation
Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture. This concept does not reflect heritage consistency. Biculturalism is a dual pattern of identification; acculturation is the process of adapting to and acquiring another culture.
12. The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment?
a. “What is your religion?”
b. “Do you mostly participate in the religious traditions of your family?”
c. “Do you smoke?”
d. “Do you have a history of heart disease?”
Asking questions about participation in the religious traditions of family enables the nurse to assess a person’s heritage. Simply asking about one’s religion, smoking history, or health history does not reflect heritage.
13. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans:
a. Have less efficient immune systems and are often ill.
b. Consider these symptoms part of normal living, not symptoms of ill health.
c. Come from Mexico, and coughing is normal and healthy there.
d. Are usually in a lower socioeconomic group and are more likely to be sick.
The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.
14. 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
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.
15. An Asian-American woman is experiencing diarrhea, which is believed to be “cold” or “yin.” The nurse expects that the woman is likely to try to treat it with:
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 is tried because diarrhea is an expected part of life.
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.
16. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects “health” in an Asian with this belief?
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.
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.
17. Illness is considered part of life’s rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory?
a. Naturalistic
b. Biomedical
c. Reductionist
d. Magicoreligious
The naturalistic perspective states that the laws of nature create imbalances, chaos, and disease. From the perspective of the Chinese, for example, illness is not considered an introducing agent; rather, illness is considered a part of life’s rhythmic course and an outward sign of disharmony within. The other options are not correct.
18. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by:
a. Germs and viruses.
b. Supernatural forces.
c. Eating imbalanced foods.
d. An imbalance within his or her spiritual nature.
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.
19. If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she:
a. Will comply with the treatment prescribed.
b. Has obviously 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.
When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.
20. An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would:
a. Contact the hospital administrator about the best course of action.
b. Automatically get a curandero for her, because requesting one herself is not culturally appropriate.
c. Further assess the patient’s cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.
d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families.
In addition to seeking help from the biomedical or scientific health care provider, patients may also seek help from folk or religious healers. Some people, 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).
21. A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse’s best course of action?
a. The nurse should focus on performing a full cardiac assessment.
b. The nurse should focus on psychosomatic complaints because the patient has just learned that his wife has cancer.
c. This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact his physician.
d. It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms.
Wide cultural variations exist in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart).
22. Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which of the following is a true statement regarding pain?
a. Nurses’ attitudes toward their patients’ pain are unrelated to their own experiences with pain.
b. Nurses need to recognize that many cultures practice silent suffering as a response to pain.
c. A nurse’s area of clinical practice will most likely determine his or her assessment of a patient’s pain.
d. A nurse’s years of clinical experience and current position are strong indicators of his or her response to patient pain.
Silent suffering is a potential response to pain in many cultures. The nurse’s assessment of pain needs to be embedded in a cultural context. The other responses are not correct.
23. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?
a. All patients will behave the same way when in pain.
b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.
c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined.
d. A patient’s expression of pain is largely dependent on the amount of tissue injury associated with the pain.
In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.
24. During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? “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. Arises out of each person’s unique life experience and his or her personal effort to find purpose in life.”
Spirituality 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.
25. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because:
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.
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.
26. 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.” This woman could be experiencing:
a. Culture shock.
b. Cultural taboos.
c. Cultural unfamiliarity.
d. Culture disorientation.
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.
27. After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? “Self-care is:
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.”
After a symptom is identified, the first effort at treatment is often self-care. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment.
28. 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.
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.
29. In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition?
a. Patient with diabetes and renal failure
b. Teenager with an abscessed tooth
c. Child with symptoms of itching and a rash
d. Older man with gastrointestinal discomfort
Illnesses believed to be caused by cold entering the body include earache, chest cramps, gastrointestinal discomfort, rheumatism, and tuberculosis. Those illnesses believed to be caused by heat, or overheating, include sore throats, abscessed teeth, rashes, and kidney disorders.
30. 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?”
The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.
31. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?
a. Believing that illness is a punishment of sin
b. Trying prayer before seeking medical help
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
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.
32. The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of:
a. Family.
b. Cultures.
c. Spirituality.
d. Subcultures.
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.
33. The nurse is reviewing concepts related to one’s heritage and beliefs. The belief in divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as:
a. Culture.
b. Religion.
c. Ethnicity.
d. Spirituality.
Religion is defined as an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. Spirituality is born out of each person’s unique life experiences and his or her personal efforts to find purpose and meaning in life. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others.
34. When planning a cultural assessment, the nurse should include which component?
a. Family history
b. Chief complaint
c. Medical history
d. Health-related beliefs
Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient’s history.
35. Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is:
a. Being rewarded for good behavior.
b. The balance of the body and spirit.
c. Maintained by wearing jade amulets.
d. Being in harmony with nature.
The belief that health is being in harmony with nature reflects the health beliefs of those of African heritages. The other examples represent Iberian and Central and South American heritages, American-Indian heritages, and Asian heritages (See Table 2-3).
MULTIPLE RESPONSE
1. The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply.
a. Examine the patient within the context of one’s own cultural health and illness practices.
b. Select questions that are not complex.
c. Ask questions rapidly.
d. Touch patients within the cultural boundaries of their heritage.
e. Pace questions throughout the physical examination.
Patients should be examined within the context of their own cultural health and illness practices. Questions should be simply stated and not rapidly asked.
2. 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. “What did your mother do to keep you from getting sick?”
e. “Have you ever had any surgeries?”
f. “How do you keep yourself healthy?”
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.
Chapter 4
1. 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
The purpose of the health history is to collect subjective data—what the person says about him or herself. The other options are not correct.
2. 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.
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.
3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 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.
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. It is enclosed in quotation marks to indicate the person’s exact words.
4. 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 last 24 hours?”
d. “Have you ever had any surgeries on your abdomen?”
A final summary of any symptom the person has should include, along with seven other critical characteristics, “Location: specific.” The person is asked to point to the location.
5. 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?”
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.
6. 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 didn’t.
d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
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).
7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
a. P-6, B-4, (S)Ab-2
b. Grav 6, Term 4, (S)Ab-2, Living 4
c. Patient has had four living babies.
d. Patient has been pregnant six times.
Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion.
8. 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.”
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.
9. 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.
Questions concerning any 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 should be asked.
10. The review of systems provides the nurse with:
a. Physical findings related to each system.
b. Information regarding health promotion practices.
c. An opportunity to teach the patient medical terms.
d. Information necessary for the nurse to diagnose the patient’s medical problem.
The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices.
11. 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 color change.
d. Lesion is noted on the lateral aspect of the right arm.
The history should be limited to patient statements or subjective data—factors that the person says were or were not present.
12. The nurse is obtaining a 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?”
Health promotion for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues.
13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?
a. “I broke my right leg in a car accident 2 weeks ago.”
b. “The pain is decreasing, but I still need to take acetaminophen.”
c. “I check the color of my toes every evening just like I was taught.”
d. “I’m able to transfer myself from the wheelchair to the bed without help.”
Functional assessment measures a person’s self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues.
14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and 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 mother?”
d. “That is a lot of stress; now let’s go on to the next section of your history.”
Questions about coping and stress management include questions regarding the kinds of stresses in one’s life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful.
15. 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.
Alcohol adversely interacts with all medications and is a factor in many social problems such as child 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.
16. 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.”
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.
17. During an assessment of a patient’s family history, the nurse constructs a genogram. Which statement best describes a genogram?
a. List of diseases present in a person’s near relatives
b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members
c. Drawing that depicts the patient’s family members up to five generations back
d. Description of the health of a person’s children and grandchildren
A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). The other options do not describe a genogram.
18. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?
a. Child’s birth weight
b. Age at which he crawled
c. Whether the child has had the measles
d. Child’s reactions to previous hospitalizations
How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.
19. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make?
a. No further MMR immunizations are needed.
b. MMR vaccination needs to be repeated at 4 to 6 years of age.
c. MMR immunization needs to be repeated every 4 years until age 21 years.
d. A recommendation cannot be made until the physician is consulted.
Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics (2006) recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years.
20. In obtaining a review of systems on a “healthy” 7-year-old girl, the health care provider knows that it would be important to include the:
a. Last glaucoma examination.
b. Frequency of breast self-examinations.
c. Date of her last electrocardiogram.
d. Limitations related to her involvement in sports activities.
When reviewing the cardiovascular system, the health care provider should ask whether any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age.
21. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?
a. Family history
b. Review of systems
c. Functional assessment
d. Reason for seeking care
Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care.
22. The nurse is obtaining a health history on 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
It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age.
23. The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation?
a. The questions asked are identical for all ages.
b. The interviewer will start incorporating different questions for patients 70 years of age and older.
c. Questions that are reflective of the normal effects of aging are added.
d. At this age, a review of systems is not necessary—the focus should be on current problems.
The health history includes the same format as that described for the younger adult, as well as some additional questions. These additional questions address ways in which the activities of daily living may have been affected by the normal aging processes or by the effects of chronic illness or disability.
24. 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?”
The person may not know the drug name or purpose. When this occurs, ask the person or a family member to bring in the drug to be identified. The other responses would not help to identify the medications.
25. 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?”
Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.
26. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
a. The functional assessment assesses how the individual is coping with life at home.
b. It determines how children are meeting developmental milestones.
c. The functional assessment can identify any problems with memory the individual may be experiencing.
d. It helps determine how a person is managing day-to-day activities.
The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.
27. The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom?
a. Chest pain
b. Clammy skin
c. Serum potassium level at 4.2 mEq/L
d. Body temperature of 100° F
A symptom is a subjective sensation (e.g., chest pain) that a person feels from a disorder. A sign is an objective abnormality that the examiner can detect on physical examination or in laboratory reports, as illustrated by the other responses.
28. A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms?
a. “It is a sharp, burning pain in my stomach.”
b. “I also have the sweats and nausea when I feel this pain.”
c. “I think this pain is telling me that something bad is wrong with me.”
d. “This pain happens every time I sit down to use the computer.”
The setting describes where the person is or what the person is doing when the symptom starts. Describing the pain as “sharp and burning” reflects the character or quality of the pain; stating that the pain is “telling” the patient that something bad is wrong with him reflects the patient’s perception of the pain; and describing the “sweats and nausea” reflects associated factors that occur with the pain.
29. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating?
a. The patient is an alcoholic.
b. The patient is annoyed at the questions.
c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms.
d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.
The CAGE test is known as the “cut down, annoyed, guilty, and eye-opener” test. If a person answers “yes” to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment.
30. The nurse is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the “community” portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions?
a. “Do you believe in God?”
b. “Are you a part of any religious or spiritual congregation?”
c. “Do you consider yourself to be a religious or spiritual person?”
d. “How does your religious faith influence the way you think about your health?”
The “community” is assessed when the nurse asks whether a person is part of a religious or spiritual community or congregation. The other areas assessed are faith, influence, and addressing any religious or spiritual issues or concerns.
31. 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?”
The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires.
32. The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history?
a. “Why did you come to the United States?”
b. “When did you come to the United States and from what country?”
c. “What made you leave your native country?”
d. “Are you planning to return to your home?”
Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions.
MULTIPLE RESPONSE
1. 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?”
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.
2. 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 a children’s vitamin?”
e. “Can he tell time?”
f. “Does he have any food allergies?”
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.
Chapter 5
1. During an examination, the nurse can assess mental status by which activity?
a. Examining the patient’s electroencephalogram
b. Observing the patient as he or she performs an intelligence quotient (IQ) test
c. Observing the patient and inferring health or dysfunction
d. Examining the patient’s response to a specific set of questions
Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects.
2. The nurse is assessing the mental status of a child. Which statement about children and mental status is true?
a. All aspects of mental status in children are interdependent.
b. Children are highly labile and unstable until the age of 2 years.
c. Children’s mental status is largely a function of their parents’ level of functioning until the age of 7 years.
d. A child’s mental status is impossible to assess until the child develops the ability to concentrate.
Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. The other statements are not true.
3. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:
a. Will have no decrease in any of his abilities, including response time.
b. Will have difficulty on tests of remote memory because this ability typically decreases with age.
c. May take a little longer to respond, but his general knowledge and abilities should not have declined.
d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.
The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.
4. When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
a. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities
Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produces frustration, suspicion, and social isolation and makes the person appear confused.
5. The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?
a. A patient’s family is the best resource for information about the patient’s coping skills.
b. Gathering mental status information during the health history interview is usually sufficient.
c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time.
d. To get a good idea of the patient’s level of functioning, performing a complete mental status examination is usually necessary.
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.
6. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action?
a. Perform a complete mental status examination.
b. Refer him to a psychometrician.
c. Plan to integrate the mental status examination into the history and physical examination.
d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.
Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.
7. The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?
a. “I sleep like a baby.”
b. “I have no health problems.”
c. “I never did too good in school.”
d. “I am not currently taking any medications.”
In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patient’s normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.
8. A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse’s best approach regarding this examination is to:
a. Plan to defer the rest of the mental status examination.
b. Skip the language portion of the examination, and proceed onto assessing mood and affect.
c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time.
d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.
In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.
9. A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:
a. She probably does not have any problems.
b. She is only trying to shock people and that her dress should be ignored.
c. She has a manic syndrome because of her abnormal dress and grooming.
d. More information should be gathered to decide whether her dress is appropriate.
Grooming and hygiene should be noted—the person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person’s economic status or a deliberate fashion trend.
10. A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:
a. May display some disruption in thought content.
b. Will state, “I am so relieved to be out of intensive care.”
c. Will be oriented to place and person, but the patient may not be certain of the date.
d. May show evidence of some clouding of his level of consciousness.
The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, “Some people have trouble keeping up with the dates while in the hospital. Do you know today’s date?” Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.
11. During a mental status examination, the nurse wants to assess a patient’s affect. The nurse should ask the patient which question?
a. “How do you feel today?”
b. “Would you please repeat the following words?”
c. “Have these medications had any effect on your pain?”
d. “Has this pain affected your ability to get dressed by yourself?”
Judge mood and affect by body language and facial expression and by directly asking, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and should appropriately change with the topics.
12. The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
a. Administer the FACT test.
b. Ask him to describe his first job.
c. Give him the Four Unrelated Words Test.
d. Ask him to describe what television show he was watching before coming to the clinic.
Ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person’s ability to lay down new memories and is a highly sensitive and valid memory test.
13. A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.
a. Invent; within 5 minutes
b. Invent; within 30 seconds
c. Recall; after a 30-minute delay
d. Recall; after a 60-minute delay
The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, “I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them.” After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.
14. During a mental status assessment, which question by the nurse would best assess a person’s judgment?
a. “Do you feel that you are being watched, followed, or controlled?”
b. “Tell me what you plan to do once you are discharged from the hospital.”
c. “What does the statement, ‘People in glass houses shouldn’t throw stones,’ mean to you?”
d. “What would you do if you found a stamped, addressed envelope lying on the sidewalk?”
A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person’s response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person’s judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations, and the capacity for violent or suicidal behavior.
15. Which of these individuals would the nurse consider at highest risk for a suicide attempt?
a. Man who jokes about death
b. Woman who, during a past episode of major depression, attempted suicide
c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself
d. Older adult man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun
When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk of physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.
16. The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girl’s mental status?
a. She clings to her mother whenever the nurse is in the room.
b. She appears angry and will not make eye contact with the nurse.
c. Her mother states that she has begun to ride a tricycle around their yard.
d. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.
The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, the nurse should follow the same Association for Behavioral and Cognitive Therapies (ABCT) guidelines as those for the adult, with special consideration for developmental milestones. The best examination technique arises from a thorough knowledge of the developmental milestones (described in Chapter 2). Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).
17. The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
a. “I know my name is John. I couldn’t tell you where I am. I think it is 2010, though.”
b. “I know my name is John, but to tell you the truth, I get kind of confused about the date.”
c. “I know my name is John; I guess I’m at the hospital in Spokane. No, I don’t know the date.”
d. “I know my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010.”
Many aging persons experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging persons oriented if they generally know where they are and the present period. They should be considered oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., hospital) and the name of the town.
18. The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant’s parents that the Denver II:
a. Tests three areas of development: cognitive, physical, and psychological
b. Will indicate whether the child has a speech disorder so that treatment can begin.
c. Is a screening instrument designed to detect children who are slow in development.
d. Is a test to determine intellectual ability and may indicate whether problems will develop later in school.
The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens.
19. A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient’s level of consciousness would be:
a. Lethargic
b. Obtunded
c. Stuporous
d. Semialert
Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased. (See Table 5-3 for the definitions of the other terms.)
20. A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, “I buy obie get spirding and take my train.” What is the best description of this patient’s problem?
a. Global aphasia
b. Broca’s aphasia
c. Echolalia
d. Wernicke’s aphasia
This type of communication illustrates Wernicke’s or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another person’s words or phrases. (See Table 5-4 for the definitions of the other disorders.)
21. A patient repeatedly seems to have difficulty coming up with a word. He says, “I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.” The nurse will note on his chart that he is using or experiencing:
a. Blocking
b. Neologism
c. Circumlocution
d. Circumstantiality
Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.
22. During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas?
a. “My stomach hurts. Hurts, spurts, burts.”
b. “Kiss, wood, reading, ducks, onto, maybe.”
c. “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.”
d. “I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.”
Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words.
PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 84 MSC: Client Needs: Psychosocial Integrity
23. A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:
a. Has a snake phobia.
b. Is a hypochondriac; snakes are usually harmless.
c. Has an obsession with snakes.
d. Has a delusion that snakes are harmful, which must stem from an early traumatic incident involving snakes.
A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. (See Table 5-7 for the definitions of the other terms.)
24. A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of:
a. Confusion
b. Ambivalence
c. Depersonalization
d. Inappropriate affect
An inappropriate affect is an affect clearly discordant with the content of the person’s speech. (See Table 5-5 for the definitions of the other terms.)
25. During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?
a. Man believes that his dead wife is talking to him.
b. Woman hears the doorbell ring and goes to answer it, but no one is there.
c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag.
d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.
Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.
26. A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient’s:
a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities
Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an alteration in mood, affect, or language abilities.
27. A patient states, “I feel so sad all of the time. I can’t feel happy even doing things I used to like to do.” He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question?
a. “Have you had any weight changes?”
b. “Are you having any thoughts of suicide?”
c. “How long have you been feeling this way?”
d. “Are you having feelings of worthlessness?”
Major depressive disorder is characterized by one or more major depressive episodes, that is, at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression. Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms.
28. A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions?
a. “How are things going with the trial?”
b. “How are things going with your job?”
c. “Tell me about your recent engagement!”
d. “Are you having any disturbing dreams?”
In posttraumatic stress disorder, the person has been exposed to a traumatic event. The traumatic event is persistently reexperienced by recurrent and intrusive, distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring.
29. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental status functioning is inferred through the assessment of an individual’s behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).
Mental status functioning is inferred through the assessment of an individual’s behaviors. It cannot be directly assessed like the characteristics of the skin or heart sounds.
30. A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
a. “How do you usually feel? Is this normal behavior for you?”
b. “I am going to say four words. In a few minutes, I will ask you to recall them.”
c. “Describe the meaning of the phrase, ‘Looking through rose-colored glasses.’”
d. “Pick up the pencil in your left hand, move it to your right hand, and place it on the table.”
Attention span is evaluated by assessing the individual’s ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span.
31. The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?
a. “Please count backward from 100 by seven.”
b. “I will name three items and ask you to repeat them in a few minutes.”
c. “Please point to articles in the room and parts of the body as I name them.”
d. “What would you do if you found a stamped, addressed envelope on the sidewalk?”
Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing (asking the person to make up and write a sentence).
32. A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse’s best response in this situation?
a. “Do you have a weapon?”
b. “How do other people treat you?”
c. “Are you feeling so hopeless that you feel like hurting yourself now?”
d. “People often feel hopeless, but the feelings resolve within a few weeks.”
When the person expresses feelings of hopelessness, despair, or grief, assessing the risk of physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions.
33. The nurse is providing instructions to newly hired graduates for the mini–mental state examination (MMSE). Which statement best describes this examination?
a. Scores below 30 indicate cognitive impairment.
b. The MMSE is a good tool to evaluate mood and thought processes.
c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.
The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.
34. The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia?
a. Global
b. Broca’s
c. Dysphonic
d. Wernicke’s
Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. (Broca’s aphasia and Wernicke’s aphasia are described in Table 5-4.) Dysphonic aphasia is not a valid condition.
35. A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” The nurse documents this as an illustration of:
a. Blocking
b. Clanging
c. Echolalia
d. Neologism
Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. (See Table 5-6 for the definitions of the other terms.)
36. During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of:
a. Social phobia
b. Compulsive disorder
c. Generalized anxiety disorder
d. Posttraumatic stress disorder
Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.
37. The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding?
a. Cognitive impairment
b. Amnesia
c. Delirium
d. Attention-deficit disorder
The Mini-Cog is a newer instrument that screens for cognitive impairment, often found with dementia. The result of an abnormal drawing of a clock and time indicates a cognitive impairment.
38. During morning rounds, the nurse asks a patient, “How are you today?” The patient responds, “You today, you today, you today!” and mumbles the words. This speech pattern is an example of:
a. Echolalia
b. Clanging
c. Word salad
d. Perseveration
Echolalia occurs when a person imitates or repeats another’s words or phrases, often with a mumbling, mocking, or a mechanical tone.
MULTIPLE RESPONSE
1. The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply.
a. Develops over a short period.
b. Person is experiencing apraxia.
c. Person is exhibiting memory impairment or deficits.
d. Occurs as a result of a medical condition, such as systemic infection.
e. Person is experiencing agnosia.
Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia.
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