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Unit 1: Health Assessment & Collecting Data
Unit 2: Demographic Profile & Physicial Examination
•A mother brings her 28-month-old daughter into the clinic for 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?
1. Tickle the toddler and get her to laugh.
2. Stoop down to her level and ask her about the toy she is holding.
3. Continue to ignore her until it is time for the physical examination.
4. Ask the mother to leave during the examination of the toddler, because toddlers often
fuss less if their parent is not in view. - CORRECT ANSWER: 2. Stoop down to her level
and ask her about the toy she is holding.
•A woman has just entered the emergency department after being 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?
1. "Hello, Nancy, my name is Nurse C."
2. "Mrs. H., my name is Nurse C. How are you?"
3. "Hello, Mrs. H., my name is Nurse C. It sure is cold today!"
4. "Mrs. H., my name is Nurse C. I'll need to ask you a few questions about what
happened." - CORRECT ANSWER: 4. "Mrs. H., my name is Nurse C. I'll need to ask
you a few questions about what happened."
•A woman is discussing the problems she is having with her 2-year-old son. She says,
"He won't go to sleep at night, and during the day he has several fits. I get so upset
,when that happens." Which is the best response by the nurse to gain a better
understanding of the problem?
1. "Go on, I'm listening."
2. "Fits? Tell me what you mean by this."
3. "Yes, it can be upsetting when a child has a fit."
4. "Don't be upset when he has a fit; every 2-year-old has fits." - CORRECT ANSWER:
2. "Fits? Tell me what you mean by this."
•As a mandatory reporter of older adult abuse, which must be present before a nurse
would notify the authorities?
1. Statements from victim
2. Statements from witnesses
3. Proof of abuse and/or neglect
4. Suspicion of older adult abuse and/or neglect - CORRECT ANSWER: 4. Suspicion of
older adult abuse and/or neglect
•During a home visit, the nurse notices that an older adult woman is caring for her
bedridden husband. The woman states that this is her duty, she does the best she can,
and her children come to help when they are in town. Her husband is unable to care for
himself, and she appears thin, weak, and exhausted. The nurse notices that several of
his prescription medication bottles are empty. What term best describes this situation?
1. Physical abuse
2. Financial exploitation
3. Psychological abuse
4. Neglect - CORRECT ANSWER: Neglect
•During an interview, a parent of a hospitalized child is sitting in a recliner with his legs
extended and his arms at his sides. As the interviewer begins to discuss his son's
treatment, he suddenly changes positions and crosses his arms against his chest and
crosses his legs. What does this change in posture suggest?
1. Simply changing positions
,2. More comfortable in this position Incorrect
3. Tired and needs a break from the interview
4. Uncomfortable talking about his son's treatment - CORRECT ANSWER: 4.
Uncomfortable talking about his son's treatment
•During an interview, the nurse states, "You mentioned having shortness of breath. Tell
me more about that." Which verbal skill is used with this statement?
1. Reflection
2. Facilitation
3. Direct question
4. Open-ended question - CORRECT ANSWER: 4. Open-ended question
•In an interview, the nurse may find it necessary to take notes to aid his or her memory
later. Which statement is true regarding note-taking?
1. Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
2. Note-taking allows the patient to continue at their own pace as the nurse records
what is said.
3. Note-taking allows the nurse to shift attention away from the patient, resulting in an
increased comfort level. Incorrect
4. Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort. - CORRECT ANSWER: 1. Note-taking may impede
the nurse's observation of the patient's nonverbal behaviors.
•In using verbal responses to assist the patient's narrative, some responses focus on
the patient's frame of reference and some focus on the health care provider's
perspective. Which type of verbal response focuses on the health care provider's
perspective?
1. Empathy
2. Reflection
3. Facilitation
, 4. Confrontation - CORRECT ANSWER: 4. Confrontation
•The nurse asks, "I would like to ask you some questions about your health and your
usual daily activities so that we can better plan your stay here." Based on this question,
the nurse is at which phase of the interview process?
1. Summary
2. Closing
3. Working
4. Opening or introduction - CORRECT ANSWER: 4. Opening or introduction
•The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these
statements describes the correct technique for this procedure? (Select all that apply.)
1. Identify any tender areas and palpate them last.
2. Warm the hands first before touching the patient.
3. Use the palms of the hands to assess temperature of the skin.
4. Start with light palpation to detect surface characteristics.
5. For deep palpation, use one long continuous palpation when assessing the liver.
6. Use the fingertips to examine skin texture, swelling, pulsation, and presence of
lumps. - CORRECT ANSWER: 1,2,4,6
•The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope?
1. Used to listen for high-pitched sounds
2. Used to listen for low-pitched sounds
3. Should be lightly held against the person's skin to block out low-pitched sounds
4. Should be lightly held against the person's skin to listen for extra heart sounds and
murmurs - CORRECT ANSWER: 1. Used to listen for high-pitched sounds
•The nurse would use bimanual palpation technique in which situation?