Chapter 06: Assessment

Chapter 06: Assessment

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The nurse is caring for a patient with pneumonia. The patient is a retired soldier who served in World War II. In light of this, the nurse should:

ANS:  A

Establishing rapport is paramount to gaining the trust of the patient. The nurse should consider the patient’s generational cohort, which may influence behavior, and willingness to share personal information during the interview process. Veterans (born before 1945) respect authority; are detail oriented; communicate in a discrete, formal, respectful way; may be slow to warm up; value family and community; and accept physical touch as an effective form of therapeutic communication. Baby Boomers (born 1946-1964) are optimistic, relationship oriented, and communicate by using open or direct speech, using body language, and answering questions thoroughly. They expect detailed information, question everything, and value success. Generation X members (born 1965-1976) are informal; are technology immigrants; multitask; communicate in a blunt or direct, factual, and informal style; may talk in short sound bites; share information frequently; and value time. Millennials (born 1977-1997) are flexible; are technologically literate or are technology natives; multitask; communicate by using action verbs and humor; may be brief in the form of texting or e-mail exchanges; like personal attention; and value individuality.

DIF:    Applying        REF:   p. 85              OBJ:   6.1                 TOP:   Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication

2. The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of the interview, the nurse should:

ANS:  B

The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of the interview, the nurse should establish the name by which the patient prefers to be addressed. Some individuals prefer formal titles of respect (e.g., Dr., Mr., Ms., Professor) and the use of surnames, whereas others are comfortable with less formality. How a patient is addressed is the patient’s choice. Demographic data should be collected by asking focused or closed-ended questions. More general information can be gathered by open-ended communication techniques. When feasible, the nurse and the patient should be seated at eye level with each other. In this way, the interaction between the nurse and the patient is horizontal instead of vertical. Standing over someone implies control, power, and authority. The implication of power can result in less-than-optimal data collection and a potential conflict as the patient strives to regain control over the situation.

DIF:    Applying        REF:   pp. 84-85       OBJ:   6.1                 TOP:   Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication

3. A nurse is conducting a health interview on a newly admitted patient. To establish a trusting relationship with the patient, the nurse:

ANS:  C

Nonverbal behaviors of the nurse can influence the information obtained from the patient. Negative nonverbal cues such as distracting gestures (e.g., tapping a pen, swinging a foot, looking at a watch), inappropriate facial expressions, and lack of eye contact communicate disinterest. To establish a trusting relationship with the patient before the physical examination is conducted, the nurse should communicate professionally, sit close and lean in slightly toward the patient, listen attentively and demonstrate appropriate eye contact, smile, and use a moderate rate of speech and tone of voice.

DIF:    Applying        REF:   p. 85              OBJ:   6.1                 TOP:   Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication

4. The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, “I just don’t feel good. I’m so hot and I feel sick to my stomach. Can you ask me those questions later?” The best response by the nurse is:

ANS:  D

If a patient being admitted to the hospital is too ill to interact for an extended period, the interview can be broken into smaller segments. Interviews with patients already hospitalized or established in the health care system are less extensive and more focused on newly identified patient concerns or problems. Ensuring that the patient is comfortable and relaxed is a priority and often takes prior thought and planning by the nurse.

DIF:    Applying        REF:   pp. 85-86       OBJ:   6.1                 TOP:   Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication