Advanced Health Assessment and Diagnostic Reasoning 4th Edition Rhoads - Test Bank Instant Download - Complete Test Bank With Answers Sample Questions Are Posted Below Chapter 1: Interview and History Taking Strategies MULTIPLE CHOICE The nurse is conducting an interview with a woman who has recently learned that she is …
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Advanced Health Assessment and Diagnostic Reasoning 4th Edition Rhoads – Test Bank
Instant Download – Complete Test Bank With Answers
Sample Questions Are Posted Below
Chapter 1: Interview and History Taking Strategies
MULTIPLE CHOICE
recently learned that she is pregnant and who has come to the
clinic today to begin prenatal care. The woman states that she and
her husband are excited about the pregnancy but have a few
questions. She looks nervously at her hands during the interview
and sighs loudly. Considering the concept of communication,
which statement does the nurse know to be most accurate? The
woman is:
about the labor.
that do not match.
is not and this is upsetting to her.
d.
Not excited about her pregnancy but believes
the nurse will negatively respond to her if she
states this.
Which receiver is most likely to misinterpret a
message sent by a health care professional?
sports physical
physical examination
lung cancer
d.
Man with a hearing impairment who uses sign
language to communicate and who has an
interpreter with him
to promote the success of an interview?
radios
and the patient to 2 feet or less
cozy and helps the patient relax
allow the patient some personal space
aid his or her memory later. Which statement is trueregarding
note-taking?
a.
Note-taking may impede the nurses
observation of the patients nonverbal
behaviors.
b.
Note-taking allows the patient to continue at
his or her own pace as the nurse records what
is said.
c.
Note-taking allows the nurse to shift attention
away from the patient, resulting in an
increased comfort level.
d.
Note-taking allows the nurse to break eye
contact with the patient, which may
increase his or her level of comfort.
health and your usual daily activities so that we can better plan
your stay here. This question is found at the phase of the
interview process.
battered by her husband. The nurse needs to get some information
from her to begin treatment. What is the best choice for an
opening phase of the interview with this patient?
cold today!
you a few questions about what happened.
shortness of breath. Tell me more about that. Which verbal
skill is used with this statement?
reason he is seeking care. When reviewing the data, the nurse
finds that some information about past hospitalizations is missing.
At this point, which statement by the nurse would be most
appropriate to gather these data?
hospitalized before!
medical records from County Medical.
c.
Mr. Y., you mentioned that you have been
hospitalized on several occasions. Would you
tell me more about that?
Mr. Y., I just need to get some additional
hospitalized before!
medical records from County Medical.
c.
Mr. Y., you mentioned that you have been
hospitalized on several occasions. Would you
tell me more about that?
d.
Mr. Y., I just need to get some additional
information about your past hospitalizations.
When was the last time you were admitted for
chest pain?
responses focus on the patients frame of reference and some focus
on the health care providers perspective. An example of a verbal
response that focuses on the health care providers perspective
would be:
notices that he often pauses and expectantly looks at the nurse.
What would be the nurses best response to this behavior?
is ready.
b.
Smile at him and say, Dont worry about all of
this. Im sure we can find out why
youre having these pains.
c.
Lean back in the chair and ask, You are
looking at me kind of funny; there isnt
anything wrong, is ther
d.
Stand up and say, I can see that this interview
is uncomfortable for you. We can
continue it another time.
c.
Lean back in the chair and ask, You are
looking at me kind of funny; there isnt
anything wrong, is ther
d.
Stand up and say, I can see that this interview
is uncomfortable for you. We can
continue it another time.
son. She says, He wont go to sleep at night, and during the day
he has several fits. I get so upset when that happens. The nurses
best verbal response would be:
old has fits.
raise a 3-year-old child by herself. During the course of the
interview she states, I cant believe my boyfriend left me to do
this by myself! What a terrible thing to do to me! Which of these
responses by the nurse uses empathy?
no picnic.
Mr. K., I know that you are lying.
b.
Mr. K., come on, tell me how much you smoke.
c.
Mr. K., I didnt realize your wife had died. It must be difficult for you at this time.
Please tell me more about that.
d.
Mr. K., you have said that you dont smoke,
but I see that you have an open pack of
cigarettes in your pocket.
or actions. After using this technique, it would be best for the
nurse to:
be demeaning for the patient.
correct the inference.
nothing has happened.
the basis of the patients nonverbal response.
longer allow my children to live with their fathers violence, but I
just cant seem to leave him. Using interpretation, the nurses best
response would be:
cant you leave?
your husband will respond.
decision. I think it is a good one.
Therapeutic response. By sharing something personal, the nurse gives hope to this woman.
b.
Nontherapeutic response. By providing false reassurance, the nurse actually cut off further
discussion o the womans fears.
c.
Therapeutic response. By providing information about the medications available, the nurse is
giving
information to the woman.
d.
Nontherapeutic response. The nurse is essentially giving the message to the woman
that labor cannot be tolerated without medication.
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:
what he is talking about.
different ways a person can quit smoking?
be very difficult. I understand how you feel.
d.
Why are you confused? Didnt the doctor give
you the information about the smoking
cessation progra
we offer?
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:
control, and then we can talk.
should discuss this later.
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:
topics.
communication, the nurse notices a discrepancy. Which
statement is true regarding this situation? The nurse
should:
help interpret this discrepancy.
to ignore the nonverbal behaviors.
c.
Try to integrate the verbal and nonverbal
messages and then interpret them as an
average.
d.
Focus on the patients nonverbal behaviors,
because these are often more reflective
of a patients true feelings.
help interpret this discrepancy.
to ignore the nonverbal behaviors.
c.
Try to integrate the verbal and nonverbal
messages and then interpret them as an
average.
d.
Focus on the patients nonverbal behaviors,
because these are often more reflective
of a patients true feelings.
an open position. As the interviewer begins to discuss his sons
treatment, however, he suddenly crosses his arms against his
chest and crosses his legs. This changed posture would suggest
that the parent is:
treatment.
a well-child visit. At the beginning of the visit, the nurse
focuses attention away from the toddler, but as the interview
progresses, the toddler begins to warm up and is smiling shyly
at the nurse. The nurse will be most successful in interacting
with the toddler if which is done next?
toy she is holding.
physical examination.
d.
Ask the mother to leave during the
examination of the toddler, because toddlers
often fuss less if their parent is not in view.
to take her blood pressure. What might the nurse do to try to gain
the childs full cooperation?
going to give her arm a big hug.
asleep and cannot wake up.
to it by this name during the assessment.
cuff, we can see how strong her muscles are.
observation after being in an automobile accident. What is the
nurses best approach to communicating with him?
respect for him.
information is unpleasant.
be kept totally confidential.
open up.
The nurse is aware that the interview may take longer than
interviews with younger persons. What is the reason for this?
have someone with whom to talk.
c.
Aged persons lose much of their mental
abilities and require longer time to complete
an interview.
d.
As a person ages, he or she is unable to hear;
thus the interviewer usually needs to
repeat much of what is said.
impairment. What techniques would be most beneficial in
communicating with this patient?
prefers.
b.
Avoid using facial and hand gestures because
most hearing-impaired people find this
degrading.
c.
Request a sign language interpreter before
meeting with him to help facilitate the
communication.
d.
Speak loudly and with exaggerated facial
movement when talking with him because
doing so will help him lip read.
her about previous pregnancies. She states that she is
remembering her last pregnancy, which ended in miscarriage. The
nurses best response to her crying would be:
is all right to cry.
youre feeling better?
dont we talk about something else?
is all right to cry.
youre feeling better?
dont we talk about something else?
immigrated. During the course of the interview, he leans forward
and then finally moves his chair close enough that his knees are
nearly touching the nurses knees. The nurse begins to feel
uncomfortable with his proximity. Which statement most closely
reflects what the nurse should do next?
are culturally appropriate for this person.
b.
The nurse should discreetly move his or her
chair back until the distance is more
comfortable, and then continue with the
interview.
c.
These behaviors are indicative of sexual
aggression, and the nurse should confront this
person about his behaviors.
d.
The nurse should laugh but tell him that he or
she is uncomfortable with his
proximity and ask him to move away.
diabetic teaching. During the interview, the nurse notices that she
never makes eye contact and speaks mostly to the floor. Which
statement is true regarding this situation?
and nonverbal behaviors.
to what the nurse is saying.
and nonverbal behaviors.
to what the nurse is saying.
language barrier, and no interpreter is available. Which is the best
example of an appropriate question for the nurse to ask in this
situation?
you?
experiencing no acute health problems. Which question or
statement by the nurse is most appropriate when beginning the
interview?
visit?
hard, but you should do what the doctor ordered because she is
the expert in this field. Which statement is correct about the
nurses comment?
shows the nurses bias.
b.
This comment is appropriate because
members of the health care team are experts
in their area of patient care.
c.
This type of comment promotes dependency
and inferiority on the part of the patient and is
best avoided in an interview situation.
d.
Using authority statements when dealing with
patients, especially when they are
undecided about an issue, is necessary at
times.
needs to choose an interpreter. Which of the following would be
the most appropriate choice?
language studies department
been taking his insulin on a regular basis. The nurse asks, Why
havent you taken your insulin? Which statement is an appropriate
evaluation of this question?
defensive.
information.
have been better.
the reasons for his behavior.
information.
have been better.
the reasons for his behavior.
Did we forget something?
b.
Is there anything else you would like to mention?
c.
I need to go on to the next patient. Ill be back.
d.
While Im here, lets talk about your upcoming surgery.
Physical
b.
Historical
c.
Objective
d.
Subjective
interview will take place at what distance?
same age as the nurse. During the interview, the patient makes an
overtly sexual comment. The nurses best reaction would be:
the interview.
that way. Please stop.
MULTIPLE RESPONSE
true regarding open-ended questions? Select all that apply.
rapport.
two-word answers.
needed.
Collect the patients data in a direct, face-to-face manner.
b.
Enter all the data as the patient states them.
c.
Ask the patient to wait as the nurse enters the data.
d.
Type the data into the computer after the narrative is fully explored.
e.
Allow the patient to see the monitor during typing.
Chapter 1: Interview and History Taking Strategies
MULTIPLE CHOICE
recently learned that she is pregnant and who has come to the
clinic today to begin prenatal care. The woman states that she and
her husband are excited about the pregnancy but have a few
questions. She looks nervously at her hands during the interview
and sighs loudly. Considering the concept of communication,
which statement does the nurse know to be most accurate? The
woman is:
about the labor.
that do not match.
is not and this is upsetting to her.
d.
Not excited about her pregnancy but believes
the nurse will negatively respond to her if she
states this.
ANS: B
Communication is all behaviors, conscious and unconscious, verbal and
nonverbal. All behaviors have meaning. Her behavior does not imply that
she is nervous about labor, upset by her husband, or worried about the
nurses response.
Which receiver is most likely to misinterpret a
message sent by a health care professional?
sports physical
physical examination
lung cancer
d.
Man with a hearing impairment who uses sign
language to communicate and who has an
interpreter with him
ANS: C
The receiver attaches meaning determined by his or her experiences,
culture, self-concept, and current physical and emotional states. The
man whose wife has just been diagnosed with lung cancer may be
experiencing emotions that affect his receiving.
to promote the success of an interview?
radios
and the patient to 2 feet or less
cozy and helps the patient relax
allow the patient some personal space
ANS: A
The nurse should reduce noise by turning off the television, radio, and
other unnecessary equipment, because multiple stimuli are confusing.
The interviewer and patient should be approximately 4 to 5 feet apart; the
room should be well-lit, enabling the interviewer and patient to see each
other clearly. Having a table or desk in between the two people creates
the idea of a barrier; equal-status seating, at eye level, is better.
aid his or her memory later. Which statement is trueregarding
note-taking?
a.
Note-taking may impede the nurses
observation of the patients nonverbal
behaviors.
b.
Note-taking allows the patient to continue at
his or her own pace as the nurse records what
is said.
c.
Note-taking allows the nurse to shift attention
away from the patient, resulting in an
increased comfort level.
d.
Note-taking allows the nurse to break eye
contact with the patient, which may
increase his or her level of comfort.
ANS: A
The use of history forms and note-taking may be unavoidable. However,
the nurse must be aware that note-taking during the interview has
disadvantages. It breaks eye contact too often and shifts the attention away
from the patient, which diminishes his or her sense of importance. Notetaking
may also interrupt the patients narrative flow, and it impedes the
observation of the patients nonverbal behavior.
health and your usual daily activities so that we can better plan
your stay here. This question is found at the phase of the
interview process.
ANS: D
When gathering a complete history, the nurse should give the reason for
the interview during the opening or introduction phase of the interview,
not during or at the end of the interview.
battered by her husband. The nurse needs to get some information
from her to begin treatment. What is the best choice for an
opening phase of the interview with this patient?
cold today!
you a few questions about what happened.
ANS: D
Address the person by using his or her surname. The nurse should
introduce him or herself and give the reason for the interview. Friendly
small talk is not needed to build rapport.
shortness of breath. Tell me more about that. Which verbal
skill is used with this statement?
ANS: D
The open-ended question asks for narrative information. It states the
topic to be discussed but only in general terms. The nurse should use it
to begin the interview, to introduce a new section of questions, and
whenever the person introduces a new topic.
reason he is seeking care. When reviewing the data, the nurse
finds that some information about past hospitalizations is missing.
At this point, which statement by the nurse would be most
appropriate to gather these data?
hospitalized before!
medical records from County Medical.
c.
Mr. Y., you mentioned that you have been
hospitalized on several occasions. Would you
tell me more about that?
Mr. Y., I just need to get some additional
hospitalized before!
medical records from County Medical.
c.
Mr. Y., you mentioned that you have been
hospitalized on several occasions. Would you
tell me more about that?
d.
Mr. Y., I just need to get some additional
information about your past hospitalizations.
When was the last time you were admitted for
chest pain?
ANS: D
The nurse should use direct questions after the persons opening narrative
to fill in any details he or she left out. The nurse also should use direct
questions when specific facts are needed, such as when asking about past
health problems or during the review of systems.
responses focus on the patients frame of reference and some focus
on the health care providers perspective. An example of a verbal
response that focuses on the health care providers perspective
would be:
ANS: D
When the health care provider uses the response of confrontation, the
frame of reference shifts from the patients perspective to the
perspective of the health care provider, and the health care provider
starts to express his or her own thoughts and feelings. Empathy,
reflection, and facilitation responses focus on the patients frame of
reference.
notices that he often pauses and expectantly looks at the nurse.
What would be the nurses best response to this behavior?
is ready.
b.
Smile at him and say, Dont worry about all of
this. Im sure we can find out why
youre having these pains.
c.
Lean back in the chair and ask, You are
looking at me kind of funny; there isnt
anything wrong, is ther
d.
Stand up and say, I can see that this interview
is uncomfortable for you. We can
continue it another time.
c.
Lean back in the chair and ask, You are
looking at me kind of funny; there isnt
anything wrong, is ther
d.
Stand up and say, I can see that this interview
is uncomfortable for you. We can
continue it another time.
ANS: A
Silent attentiveness communicates that the person has time to think and to
organize what he or she wishes to say without an interruption from the
nurse. Health professionals most often interrupt this thinking silence. The
other responses are not conducive to ideal communication.
son. She says, He wont go to sleep at night, and during the day
he has several fits. I get so upset when that happens. The nurses
best verbal response would be:
old has fits.
ANS: B
The nurse should use clarification when the persons word choice is
ambiguous or confusing (e.g., Tell me what you mean by fits.).
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.
raise a 3-year-old child by herself. During the course of the
interview she states, I cant believe my boyfriend left me to do
this by myself! What a terrible thing to do to me! Which of these
responses by the nurse uses empathy?
no picnic.
ANS: C
An empathetic response recognizes the feeling and puts it into words. It
names the feeling, allows its expression, and strengthens rapport. Other
empathetic responses are, This must be very hard for you, I understand, or
simply placing your hand on the persons arm. Simply reflecting the
persons words or agreeing with the person is not an empathetic response.
Mr. K., I know that you are lying.
b.
Mr. K., come on, tell me how much you smoke.
c.
Mr. K., I didnt realize your wife had died. It must be difficult for you at this time.
Please tell me more about that.
d.
Mr. K., you have said that you dont smoke,
but I see that you have an open pack of
cigarettes in your pocket.
ANS: D
In the case of confrontation, a certain action, feeling, or statement has
been observed, and the nurse now focuses the patients attention on it. The
nurse should give honest feedback about what is seen or felt.
Confrontation may focus on a discrepancy, or the nurse may confront the
patient when parts of the story are inconsistent. The other statements are
not appropriate.
or actions. After using this technique, it would be best for the
nurse to:
be demeaning for the patient.
correct the inference.
nothing has happened.
the basis of the patients nonverbal response.
ANS: B
Interpretation is not based on direct observation as is confrontation, but it
is based on ones inference or conclusion. The nurse risks making the
wrong inference. If this is the case, then the patient will correct it.
However, even if the inference is correct, interpretation helps prompt
further discussion of the topic.
longer allow my children to live with their fathers violence, but I
just cant seem to leave him. Using interpretation, the nurses best
response would be:
cant you leave?
your husband will respond.
decision. I think it is a good one.
ANS: C
This statement is not based on ones inference or conclusion. It links
events, makes associations, or implies cause. Interpretation also ascribes
feelings and helps the person understand his or her own feelings in
relation to the verbal message. The other statements do not reflect
interpretation.
Therapeutic response. By sharing something personal, the nurse gives hope to this woman.
b.
Nontherapeutic response. By providing false reassurance, the nurse actually cut off further
discussion o the womans fears.
c.
Therapeutic response. By providing information about the medications available, the nurse is
giving
information to the woman.
d.
Nontherapeutic response. The nurse is essentially giving the message to the woman
that labor cannot be tolerated without medication.
ANS: B
By providing false assurance or reassurance, this courage builder
relieves the womans anxiety and gives the nurse the false sense of
having provided comfort. However, for the woman, providing false
assurance or reassurance actually closes off communication, trivializes
her anxiety, and effectively denies any further talk of it.
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:
what he is talking about.
different ways a person can quit smoking?
be very difficult. I understand how you feel.
d.
Why are you confused? Didnt the doctor give
you the information about the smoking
cessation progra
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 unwanted advice
or do not offer a helpful response.
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:
control, and then we can talk.
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.
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:
topics.
ANS: C
This question is an example of using leading or biased questions. Asking,
You dont smoke, do you? implies that one answer is better than another.
If the person wants to please someone, then he or she is either forced to
answer in a way that corresponds to his or her implied values or is made
to feel guilty when admitting the other answer.
communication, the nurse notices a discrepancy. Which
statement is true regarding this situation? The nurse
should:
help interpret this discrepancy.
to ignore the nonverbal behaviors.
c.
Try to integrate the verbal and nonverbal
messages and then interpret them as an
average.
d.
Focus on the patients nonverbal behaviors,
because these are often more reflective
of a patients true feelings.
help interpret this discrepancy.
to ignore the nonverbal behaviors.
c.
Try to integrate the verbal and nonverbal
messages and then interpret them as an
average.
d.
Focus on the patients nonverbal behaviors,
because these are often more reflective
of a patients true feelings.
ANS: D
When nonverbal and verbal messages are congruent, the verbal
message is reinforced. When they are incongruent, the nonverbal
message tends to be the true one because it is under less conscious
control. Thus studying the nonverbal messages of the patients and
examiners and understanding their meanings are important. The other
statements are not true.
an open position. As the interviewer begins to discuss his sons
treatment, however, he suddenly crosses his arms against his
chest and crosses his legs. This changed posture would suggest
that the parent is:
treatment.
ANS: D
The persons position is noted. An open position with the extension of
large muscle groups shows relaxation, physical comfort, and a willingness
to share information. A closed position with the arms and legs crossed
tends to look defensive and anxious. Any change in posture should be
noted. If a person in a relaxed position suddenly tenses, then this change
in posture suggests possible discomfort with the new topic.
a well-child visit. At the beginning of the visit, the nurse
focuses attention away from the toddler, but as the interview
progresses, the toddler begins to warm up and is smiling shyly
at the nurse. The nurse will be most successful in interacting
with the toddler if which is done next?
toy she is holding.
physical examination.
d.
Ask the mother to leave during the
examination of the toddler, because toddlers
often fuss less if their parent is not in view.
ANS: B
Although most of the communication is with the parent, the nurse should
not completely ignore the child. Making contact will help ease the toddler
later during the physical examination. The nurse should begin by asking
about the toys the child is playing with or about a special doll or teddy
bear brought from home. Does your doll have a name? or What can your
truck do? Stoop down to meet the child at his or her eye level.
to take her blood pressure. What might the nurse do to try to gain
the childs full cooperation?
going to give her arm a big hug.
asleep and cannot wake up.
to it by this name during the assessment.
cuff, we can see how strong her muscles are.
ANS: D
Take the time to give a short, simple explanation with a concrete
explanation for any unfamiliar equipment that will be used on the child.
Preschoolers are animistic; they imagine inanimate objects can come
alive and have human characteristics. Thus a blood pressure cuff can
wake up and bite or pinch.
observation after being in an automobile accident. What is the
nurses best approach to communicating with him?
respect for him.
information is unpleasant.
be kept totally confidential.
open up.
ANS: B
Successful communication with an adolescent is possible and can be
rewarding. The guidelines are simple. The first consideration is ones
attitude, which must be one of respect. Second, communication must be
totally honest. An adolescents intuition is highly tuned and can detect
phoniness or the withholding of information. Always tell him or her the
truth.
The nurse is aware that the interview may take longer than
interviews with younger persons. What is the reason for this?
have someone with whom to talk.
c.
Aged persons lose much of their mental
abilities and require longer time to complete
an interview.
d.
As a person ages, he or she is unable to hear;
thus the interviewer usually needs to
repeat much of what is said.
ANS: A
The interview usually takes longer with older adults because they have a
longer story to tell. It is not necessarily true that all older adults are
lonely, have lost mental abilities, or are hard of hearing.
impairment. What techniques would be most beneficial in
communicating with this patient?
prefers.
b.
Avoid using facial and hand gestures because
most hearing-impaired people find this
degrading.
c.
Request a sign language interpreter before
meeting with him to help facilitate the
communication.
d.
Speak loudly and with exaggerated facial
movement when talking with him because
doing so will help him lip read.
ANS: A
The nurse should ask the deaf person the preferred way to communicateby
signing, lip reading, or writing. If the person prefers lip reading, then the
nurse should be sure to face him squarely and have good lighting on the
nurses face. The nurse should not exaggerate lip movements because this
distorts words. Similarly, shouting distorts the reception of a hearing aid
the person may wear. The nurse should speak slowly and supplement his
or her voice with appropriate hand gestures or pantomime.
her about previous pregnancies. She states that she is
remembering her last pregnancy, which ended in miscarriage. The
nurses best response to her crying would be:
is all right to cry.
youre feeling better?
dont we talk about something else?
is all right to cry.
youre feeling better?
dont we talk about something else?
ANS: B
A beginning examiner usually feels horrified when the patient starts
crying. When the nurse says something that makes the person cry, the
nurse should not think he or she has hurt the person.
The nurse has simply hit on an important topic; therefore, moving on to a
new topic is essential. The nurse should allow the person to cry and to
express his or her feelings fully. The nurse can offer a tissue and wait
until the crying subsides to talk.
immigrated. During the course of the interview, he leans forward
and then finally moves his chair close enough that his knees are
nearly touching the nurses knees. The nurse begins to feel
uncomfortable with his proximity. Which statement most closely
reflects what the nurse should do next?
are culturally appropriate for this person.
b.
The nurse should discreetly move his or her
chair back until the distance is more
comfortable, and then continue with the
interview.
c.
These behaviors are indicative of sexual
aggression, and the nurse should confront this
person about his behaviors.
d.
The nurse should laugh but tell him that he or
she is uncomfortable with his
proximity and ask him to move away.
ANS: A
Both the patients and the nurses sense of spatial distance are significant
throughout the interview and physical examination, with culturally
appropriate distance zones varying widely. Some cultural groups value
close physical proximity and may perceive a health care provider who is
distancing him or herself as being aloof and unfriendly.
diabetic teaching. During the interview, the nurse notices that she
never makes eye contact and speaks mostly to the floor. Which
statement is true regarding this situation?
and nonverbal behaviors.
to what the nurse is saying.
and nonverbal behaviors.
to what the nurse is saying.
ANS: D
Eye contact is perhaps among the most culturally variable nonverbal
behaviors. Asian, American Indian, Indochinese, Arabian, and
Appalachian people may consider direct eye contact impolite or
aggressive, and they may avert their eyes during the interview. American
Indians often stare at the floor during the interview, which is a culturally
appropriate behavior, indicating that the listener is paying close attention
to the speaker.
language barrier, and no interpreter is available. Which is the best
example of an appropriate question for the nurse to ask in this
situation?
you?
ANS: A
In a situation during which a language barrier exists and no interpreter is
available, simple words should be used, avoiding medical jargon. The use
of contractions and pronouns should also be avoided. Nouns should be
repeatedly used, and one topic at a time should be discussed.
experiencing no acute health problems. Which question or
statement by the nurse is most appropriate when beginning the
interview?
visit?
ANS: D
Open-ended questions are used for gathering narrative information. This
type of questioning should be used to begin the interview, to introduce a
new section of questions, and whenever the person introduces a new
topic.
hard, but you should do what the doctor ordered because she is
the expert in this field. Which statement is correct about the
nurses comment?
shows the nurses bias.
b.
This comment is appropriate because
members of the health care team are experts
in their area of patient care.
c.
This type of comment promotes dependency
and inferiority on the part of the patient and is
best avoided in an interview situation.
d.
Using authority statements when dealing with
patients, especially when they are
undecided about an issue, is necessary at
times.
ANS: C
Using authority responses promotes dependency and inferiority. Avoiding
the use of authority is best. Although the health care provider and patient
do not have equal professional knowledge, both have equally worthy
roles in the health process. The other statements are not correct.
needs to choose an interpreter. Which of the following would be
the most appropriate choice?
language studies department
ANS: A
Whenever possible, the nurse should use a trained interpreter, preferably
one who knows medical terminology. In general, an older, more mature
interpreter is preferred to a younger, less experienced one, and the same
gender is preferred when possible.
been taking his insulin on a regular basis. The nurse asks, Why
havent you taken your insulin? Which statement is an appropriate
evaluation of this question?
defensive.
information.
have been better.
the reasons for his behavior.
information.
have been better.
the reasons for his behavior.
ANS: A
The adults use of why questions usually implies blame and
condemnation and places the person on the defensive. The other
statements are not correct.
Did we forget something?
b.
Is there anything else you would like to mention?
c.
I need to go on to the next patient. Ill be back.
d.
While Im here, lets talk about your upcoming surgery.
ANS: B
This question offers the person a final opportunity for self-expression.
No new topic should be introduced. The other questions are not
appropriate.
Physical
b.
Historical
c.
Objective
d.
Subjective
ANS: D
The interview is the first, and really the most important, part of data
collection. During the interview, the nurse collects subjective data; that is,
what the person says about him or herself.
interview will take place at what distance?
ANS: C
Social distance, 4 to 12 feet, is usually the distance category for most of
the interview. Public distance, over 12 feet, is too much distance; the
intimate zone is inappropriate, and the personal distance will be used for
the physical assessment.
same age as the nurse. During the interview, the patient makes an
overtly sexual comment. The nurses best reaction would be:
the interview.
that way. Please stop.
ANS: D
The nurses response must make it clear that she is a health professional
who can best care for the person by maintaining a professional
relationship. At the same time, the nurse should communicate that he or
she accepts the person and understands the persons need to be selfassertive
but that sexual advances cannot be tolerated.
MULTIPLE RESPONSE
true regarding open-ended questions? Select all that apply.
rapport.
two-word answers.
needed.
ANS: B, C, F
Open-ended questions allow for self-expression, build and enhance
rapport, and obtain narrative information. These features enhance
communication during an interview. The other statements are appropriate
for closed or direct questions.
Collect the patients data in a direct, face-to-face manner.
b.
Enter all the data as the patient states them.
c.
Ask the patient to wait as the nurse enters the data.
d.
Type the data into the computer after the narrative is fully explored.
e.
Allow the patient to see the monitor during typing.
ANS: A, D, E
The use of a computer can become a barrier. The nurse should begin the
interview as usual by greeting the patient, establishing rapport, and
collecting the patients narrative story in a direct, face-to-face manner.
Only after the narrative is fully explored should the nurse type data into
the computer. When typing, the nurse should position the monitor so that
the patient can see it.
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Original price was: $30.00.$20.00Current price is: $20.00.
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