Chapter 07 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 07 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCMA

While interviewing the client during the focused interview, the client begins to cry softly. Which interventions by the nurse are appropriate?

Standard Text: Select all that apply.

1. The nurse states, “It’s all right, I think we’re done with the interview.”
2. The nurse places the tissues within arm’s reach of the client.
3. The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview.
4. The nurse states, “I don’t like these questions any more than you do, but we need to get on with the interview so you can go home and cry later.”
5. The nurse states, “I can see you are upset. It’s all right to cry.”

Correct Answer: 2, 3, 5

Rationale 1: It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning.

Rationale 2: When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client.

Rationale 3: It is appropriate for the nurse to remain quiet while the client cries.

Rationale 4: The nurse should not hurry the interview along or not provide time for the client to display emotion.

Rationale 5: It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad.

Global Rationale: When the client begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues within close proximity to the client. It is appropriate for the nurse to remain quiet while the client cries. It is appropriate for the nurse to give the client permission to cry. Some people need the assurance that it is okay to cry and feel sad. It is not appropriate to conclude the interview. There may be something that can help the nurse create a better care plan for the client if the nurse continues with this line of questioning. The nurse should not hurry the interview along or not provide time for the client to display emotion.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–115

 

Question 2

Type: MCMA

The nurse recently gave birth to a stillborn infant. During the pre-interaction stage, the nurse learns that the client has had five elective abortions performed while she was in high school and college. Which nursing actions are appropriate to help the nurse prepare emotionally for the initial interview with this client?

Standard Text: Select all that apply.

1. The nurse speaks with one of her nursing peers and sets up a time to role-play the interview.
2. The nurse writes in her journal regarding her fears about meeting with the client.
3. The nurse makes an appointment to meet with her counselor prior to the interview.
4. The nurse should remain very quiet during the interview so that the initial interview will only last for a brief time.
5. The nurse creates a list of her own goals to accomplish during the interview with this client.

Correct Answer: 1, 2, 3, 5

Rationale 1: The nurse should speak with one of her nursing peers to role-play how the interview may proceed.

Rationale 2: The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client.

Rationale 3: The nurse can make an appointment to speak with her counselor about her feelings prior to the interview.

Rationale 4: The nurse will not be able to elicit an adequate amount of information from the client if she is focusing only on being quiet during the interview.

Rationale 5: The nurse can create a list of goals to accomplish during the interview.

Global Rationale: The nurse should speak with one of her nursing peers to role-play how the interview may proceed. The nurse can write in a journal about some of her fears regarding the upcoming meeting with the client. The nurse can make an appointment to speak with her counselor about her feelings prior to the interview. The nurse can create a list of goals to accomplish during the interview. The nurse will not be able to elicit an adequate amount of information if she is focusing only on being quiet during the interview.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A.9. Discuss principles of effective communication.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Identify strategies that promote effective communication when conducting a health history.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–115

 

Question 3

Type: MCMA

The student nurse and the experienced nurse are meeting with an elderly Vietnamese client who is unable to speak English. Which actions indicate that the student nurse requires further education?

Standard Text: Select all that apply.

1. The student nurse looks intently at the translator during the interview.
2. The student nurse is sitting directly beside the client and both of them are facing the translator.
3. The student nurse asks one question at a time.
4. The student nurse has requested that the client bring his daughter to the interview to translate for him.
5. The student nurse states, “Please tell him to void in this specimen container and to use a clean-catch technique when acquiring the urine.”

Correct Answer: 1, 2, 4, 5

Rationale 1: The student nurse should look at the client during the interview, not at the translator.

Rationale 2: The student nurse should sit across from the client. The translator should sit next to the client.

Rationale 3: The student nurse should ask one question at a time.

Rationale 4: The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation.

Rationale 5: The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well.

Global Rationale: The student nurse should look at the client during the interview, not at the translator. The student nurse should sit across from the client. The translator should sit next to the client. The student nurse should not request that the client use his daughter as the translator. The student nurse should use language assistive services that health care agencies must provide at all points of contact, during all hours of operation. The student nurse should avoid using any medical jargon. This may be difficult for the translator to understand and translate well. The student nurse should ask one question at a time.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families.

AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network.

NLN Competencies: Teamwork: Effective strategies for communicating with different members of the health team, including patients and families.

Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Explain the potential effects of cultural and lifespan influences on communication between the nurse and the patient.

MNL Learning Outcome: 2.1.1. Apply appropriate communication skills required to conduct the health history interview of a client.

Page Number: pp. 113–115; 117