TEST BANK Advanced Health Assessment and Differential Diagnosis Essentials for Clinical Practice 1st Edition Myrick
Advanced Health Assessment and
... [Show More] Differential Diagnosis Essentials for
Clinical Practice 1st Edition Myrick Test Bank
Chapter 1. Health History, The Patient Interview, And Motivational Interviewing
MULTIPLE CHOICE
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 patients biographic information
c.
To document the normal and abnormal findings of a physical assessment
d.
To provide a database of subjective information about the patients past and
current health
ANS: D
The purpose of the health history is to collect subjective datawhat the person says about him or
herself. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 49
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. When the nurse is evaluating the reliability of a patients responses, which of these statements
would be correct? The patient:
a.
Has a history of drug abuse and therefore is not reliable.
b.
Provided consistent information and therefore is reliable.
c.
Smiled throughout interview and therefore is assumed reliable.
d.
Would not answer questions concerning stress and therefore is not reliable.
ANS: B
A reliable person always gives the same answers, even when questions are rephrased or are
repeated later in the interview. The other statements are not correct.
DIF: Cognitive Level: Applying (Application) REF: dm. 49
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
ANS: D
The reason for seeking care is a brief spontaneous statement in the persons 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 persons exact words.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the
nurses best response?
a.
Can you point to where it hurts?
b.
Well 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?
ANS: A
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.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would
be the nurses appropriate response to the womans statement?
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a.
How does your family react to your pain?
b.
The pain must be terrible. You probably pinched a nerve.
c.
Ive had back pain myself, and it can be excruciating.
d.
How would you say the pain affects your ability to do your daily activities?
ANS: D
The symptom of pain is difficult to quantify because of individual interpretation. With pain,
adjectives should be avoided and the patient should be asked how the pain affects his or her daily
activities. The other responses are not appropriate.
DIF: Cognitive Level: Applying (Application) REF: dm. 50
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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 didnt.
d.
Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
ANS: D
Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat.
Avoid recording usual childhood illnesses because an illness common in the persons childhood
may be unusual today (e.g., measles).
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 51
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
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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.
ANS: B
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.
DIF: Cognitive Level: Applying (Application) REF: dm. 51
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. A patient tells the nurse that he is allergic to penicillin. What would be the nurses best
response to this information?
a.
Are you allergic to any other drugs?
b.
How often have you received penicillin?
c.
Ill write your allergy on your chart so you wont receive any penicillin.
d.
Describe what happens to you when you take penicillin.
ANS: D
Note both the allergen (medication, food, or contact agent, such as fabric or environmental
agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). With a
drug, this symptom should not be a side effect but a true allergic reaction.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 52
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
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a.
Emphysema.
b.
Head trauma.
c.
Mental illness.
d.
Fractured bones.
ANS: C
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.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 53-54
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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 patients medical problem.
ANS: B
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.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 54
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
11. Which of these statements represents subjective data the nurse obtained from the patient
regarding the patients 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.
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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.
ANS: C
The history should be limited to patient statements or subjective datafactors that the person says
were or were not present.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 54
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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?
ANS: A
Health promotion for a man would include the performance of testicular self-examinations. The
other questions are asking about possible disease or illness issues.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 56
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.Im able to transfer myself from the wheelchair to the bed without help.
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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.
Im able to transfer myself from the wheelchair to the bed without help.
ANS: D
Functional assessment measures a persons self-care ability in the areas of general physical health
or absence of illness. The other statements concern health or illness issues.
DIF: Cognitive Level: Applying (Application) REF: dm. 56
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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 dont 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 lets go on to the next section of your history.
ANS: C
Questions about coping and stress management include questions regarding the kinds of stresses
in ones 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.
DIF: Cognitive Level: Applying (Application) REF: dm. 57
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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 patients reliability.
b.
Alcohol can interact with all medications and can make some diseases worse.
c.
The nurse needs to be able to teach the patient about the dangers of alcohol use.
d.
This information is not necessary unless a drinking problem is obvious.
ANS: B
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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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 58
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
ANS: D
With a very young child, the parent is asked, How do you know the child is in pain? A young
child pulling at his or her ears should alert parents to the childs 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 a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop
smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What
should I do? The nurses most appropriate response in this case would be:
a.
Id quit if I were you. The doctor really knows what he is talking about.
b.
Would you like some information about the different ways a person can quit
smoking?
c.
Stopping your dependence on cigarettes can be very difficult. I understand how
you feel.
d.
Why are you confused? Didnt the doctor give you the information about the
smoking cessation program we offer?
ANS: B
Clarification should be used when the persons word choice is ambiguous or confusing.
Clarification is also used to summarize the persons words or to simplify the words to make them
clearer; the nurse should then ask if he or she is on the right track. The other responses give
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unwanted advice or do not offer a helpful response.
DIF: Cognitive Level: Applying (Application) REF: dm. 33
MSC: Client Needs: Psychosocial Integrity
18. As the nurse enters a patients room, the nurse finds her crying. The patient states that she has
just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The
nurses most therapeutic response would be to say in a gentle manner:
a.
Youre afraid you might lose your breast?
b.
No, Im not sure what you are talking about.
c.
Ill wait here until you get yourself under control, and then we can talk.
d.
I can see that you are very upset. Perhaps we should discuss this later.
ANS: A
Reflection echoes the patients words, repeating part of what the person has just said. Reflection
can also help express the feelings behind a persons words.
DIF: Cognitive Level: Applying (Application) REF: dm. 33
MSC: Client Needs: Psychosocial Integrity
19. A nurse is taking complete health histories on all of the patients attending a wellness
workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take
drugs, do you? This question is an example of:
a.
Talking too much.
b.
Using confrontation.
c.
Using biased or leading questions.
d.
Using blunt language to deal with distasteful topics. [Show Less]