TEST BANK for Seidels Guide to Physical Examination 8th Edition by Ball.

TEST BANK

Chapter 01: The History and Interviewing Process Test Bank—Nursing MULTIPLE CHOICE 1. The primary objective of the initial encounter is to: a. define the advice and care for the patient. b. establish the tone of a successful partnership. c. optimize your ability to help. d. tell the patient the limits of care. ANS: B

The first meeting with the patient sets the tone for a successful partnership. It is to discover the details about patients’ concerns, explore expectations for the encounter, display genuine interest, and develop a partnership. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 1 OBJ: Nursing process—assessment MSC: Safe and Effective Care: Management of Care 2. If language is a barrier, the interpreter should be: a. a family member. b. a language board. c. a professional interpreter d. a staff person. ANS: C

Someone other than a family member should act as an interpreter to bridge the language difference between a health care provider and the patient. A professional interpreter rather than a family member should be used. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 4 OBJ: Nursing process—assessment MSC: Safe and Effective Care: Management of Care 3. Mary Jane has brought in her 16-year-old son, Kyle. She states that he has been sleeping more

and does not hang around his friends, and recently his girlfriend broke up with him. Your most immediate question is to ask Kyle: a. “Do you want to see a counselor today?” b. “Is your father out of jail yet?” c. “Are you taking any illegal drugs?” d. “Have you made plans to harm yourself?” ANS: D

If you sense that a patient is contemplating suicide, you should ask about suicidal ideation directly. The most important area to address is the potential for suicide. The question “Is your father out of jail yet?” may be relevant to the history, but is not an immediate concern. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 5 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. Ms. Yale is a 52-year-old patient who presents to the office for evaluation. During the

interview, you say “Tell me what you do when you have knee pain.” The health care provider is asking information about: a. health promotion. b. the description and character of the complaint. c. the location and duration of the complaint. d. aggravating and relieving factors of the complaint. ANS: D

The health care provider is asking a symptom-analysis question to obtain more information about the aggravating and alleviating factors of the knee pain. Asking the patient to describe a typical attack of pain would help obtain information about the description and character of the complaint. The question “When did you last feel well?” would help define the time of onset and duration of the complaint. A question about health promotion would be directed toward improving patient health. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 11 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Which question would be considered a “leading question?” a. “What do you think is causing your headaches?” b. “You don’t get headaches often, do you?” c. “On a scale of 1 to 10, how would you rate the severity of your headaches?” d. “At what time of the day are your headaches the most severe?” ANS: B

Stating to the patient that he or she does not get headaches would limit the information in the patient’s answer. Asking the patient what he or she thinks is causing the headaches is an openended question. Asking the patient how he or she would rate the severity of the headaches and asking what time of the day the headaches are the most severe are direct questions. DIF: Cognitive Level: Applying (Application) REF: p. 4 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. To prevent personal appearance from becoming an obstacle in patient care, the health care

professional should: a. wear a uniform. b. avoid wearing white. c. avoid extremes in dress. d. avoid wearing any jewelry. ANS: C

Sensible personal habits, along with avoidance of extremes in behavior and dress, contribute to establishing a trusting relationship between the care provider and the patient. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 3 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. Which action would best promote accurate translation and confidentiality when the caregiver

does not speak the patient’s language? a. Ask a person unfamiliar with the patient to translate. b. Have a friend of the patient translate.

c. Involve the family with the translation. d. Use a neighbor as translator. ANS: A

When you do not speak the patient’s language, family members or friends may pose a communication barrier and may have issues of confidentiality; a stranger will be a less biased interpreter. You should ask a person unfamiliar with the patient to translate. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. When are open-ended questions generally most useful? a. During the initial part of the interview. b. After several closed-ended questions have been asked. c. While designing the genogram. d. During the review of systems. ANS: A

Asking open-ended questions at the beginning of an interview allows you to gather more information and establishes you as an empathic listener, which is the first step of effective communication. Interviewing for the purpose of designing a genogram or conducting a review of systems requires more focused data than can be more easily gathered with direct questioning. Asking closed-ended questions may stifle the patient’s desire to discuss the history of the illness. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Behaviors that diffuse anxiety during the interview include: a. avoiding wearing uniforms or laboratory coats. b. providing forthright answers to questions. c. providing all necessary information before the patient has to ask for it. d. completing the interview as quickly as possible. ANS: B

To relieve anxiety, the health care professional should answer patient questions forthrightly, should avoid an overload of information, and should not hurry the conversation. Uniforms, lab coats, and scrub suits are common in health care. It is impossible to anticipate every question that a patient may ask. Completing the interview as quickly as possible may make the patient feel rushed. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Periods of silence during the interview can serve important purposes, such as: a. allowing the clinician to catch up on documentation. b. promoting calm. c. providing time for reflection. d. increasing the length of the visit. ANS: C

Silence is a useful tool during interviews for the purposes of reflection, summoning courage, and displaying compassion. This is not a time to document in the chart, but rather to focus on the patient. Periods of silence may cause anxiety rather than promote calm. The length of the visit is less important than getting critical information. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Which technique is most likely to result in the patient’s understanding of questions? a. Use phrases that are commonly used by other patients in the area. b. Use the patient’s own terms if possible. c. Use the simplest language possible. d. Use proper medical and technical terminology. ANS: B

To ensure that your questions have been correctly understood, be clear and explicit while using the patient’s own terms and level of understanding. Using phrases commonly used by other patients may not help ensure that your questions have been correctly understood by this patient. You should be clear and explicit while using the patient’s own terms and level of understanding. Using the simplest language will not help ensure that your questions have been correctly understood. It is important to avoid the use of medical terminology, because the patient may not understand it. DIF: Cognitive Level: Applying (Application) REF: p. 2 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Mr. Franklin is speaking with you, the health care provider, about his respiratory problem. Mr.

Franklin says, “I’ve had this cough for 3 days, and it’s getting worse.” You reply, “Tell me more about your cough.” Mr. Franklin states, “I wish I could tell you more. That’s why I’m here. You tell me what’s wrong!” Which caregiver response would be most appropriate for enhancing communication? a. “After 3 days, you’re tired of coughing. Have you had a fever?” b. “I’d like to hear more about your experiences. Where were you born?” c. “I don’t know what’s wrong. You could have almost any disease.” d. “I’ll examine you and figure out later what the problem is.” ANS: A

“After 3 days, you’re tired of coughing. Have you had a fever?” is the only response aimed at focusing on the chief compliant to gather more data and does not digress from the issue. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 5 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. Mr. Miller is a 46-year-old patient who becomes restless during the history and says, “I don’t

have time for all of this conversation. I’ve got to get back to work.” Your most appropriate response would be to: a. remember (acknowledge) his anger and proceed with the history and examination. b. ask another open-ended question and insist on an answer. c. ask questions about his anger and move closer to him. d. ignore his displeasure and become more assertive about getting answers. ANS: A

Acknowledging his anger and proceeding with the history and examination is the only response that resists the tendency for patient manipulation, pursues the information, and confronts the anger. DIF: Cognitive Level: Applying (Application) REF: p. 5 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. When you are questioning a patient regarding alcohol intake, she tells you that she is “only a

social drinker.” Which initial response is appropriate? a. “I’m glad that you are a responsible drinker.” b. “Do the other people in your household consume alcohol?” c. “What amount and what kind of alcohol do you drink in a week?” d. “If you only drink socially, you won’t need to worry about always having a designated driver.” ANS: C

“What amount and what kind of alcohol do you drink in a week?” clarifies the patient’s own statement without asking a leading question or being judgmental. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 8 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Ms. T is crying and states that her mother couldn’t possibly have a tumor. “No one else in the

family has ever had cancer!” exclaims the daughter. The most appropriate response to Ms. T would be: a. “Has anyone explained hospice care to your mother?” b. “I’m so sorry that your mother was diagnosed with cancer.” c. “That is odd, since cancer usually runs in families.” d. “Why do you think that your mother’s tumor is cancerous?” ANS: D

“Why do you think that your mother’s tumor is cancerous?” is the only answer that is a direct exploration of the daughter’s concern. The health care provider can address and clarify the concerns of the daughter. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 5 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. After you ask a patient about her family history, she says, “Tell me about your family now.”

Which response is generally most appropriate? a. Ignore the patient’s comment and continue with the interview. b. Give a brief, undetailed answer. c. Ask the patient why she needs to know. d. Tell the patient that you do not discuss your family with patients. ANS: B

Giving a brief, undetailed answer will satisfy the patient’s curiosity about yourself without invading your private life. Ignoring the patient’s comment, continuing with the interview, and telling the patient that you do not discuss your family with patients will potentially anger or frustrate her and keep her from sharing openly. Asking the patient why she needs to know will distract from the real reason she is seeking care and instead move the interview conversation away from the topics that should be discussed.

DIF: Cognitive Level: Applying (Application) REF: p. 4 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. A 36-year-old woman complains that she has had crushing chest pain for the past 2 days. She

seems nervous as she speaks to you. An appropriate response is to: a. continue to collect information regarding the chief complaint in an unhurried manner. b. finish the interview as rapidly as possible. c. ask the patient to take a deep breath and calm down. d. ask the patient if she wants to wait until another day to talk to you. ANS: A

With an anxious, vulnerable patient, it is best to not hurry; a calm demeanor will communicate caring to the patient. If you as the health care provider are hurried, the patient will be more anxious. The best way to assist an anxious patient is to not hurry and remain calm, because this will communicate caring to the patient. Asking the patient if she wants to wait until another day to talk to you delays the needed health care. DIF: Cognitive Level: Applying (Application) REF: p. 4 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. Ms. A states, “My life is just too painful. It isn’t worth it.” She appears depressed. Which one

of the following statements is the most appropriate caregiver response? a. “Try to think about the good things in life.” b. “What in life is causing you such pain?” c. “You can’t mean what you’re saying.” d. “If you think about it, nothing is worth getting this upset about.” ANS: B

Specific but open-ended questions are best used when the patient has feelings of loss of selfworth and depression. “Try to think about the good things in life,” “You can’t mean what you’re saying,” and “If you think about it, nothing is worth getting this upset about” are statements that will hurry the patient and offer only superficial assurance. DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 4-6 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. During an interview, tears appear in the patient’s eyes and his voice becomes shaky. Initially,

you should: a. ask him if he would like some time alone. b. offer a tissue and let him know it is all right to cry. c. explain to the patient that you will be able to help him more if he can control his emotions. d. ask the patient what he is upset about. ANS: B

When patients cry, it is best to allow the moment to pass at the patient’s pace. If you suspect a need to cry but the patient is suppressing it, give permission. Asking him if he would like some time to himself will leave the patient alone during a time of sad feelings. Explaining to the patient that you will be able to help him more if he can control his emotions will shut down the patient’s emotions. Asking the patient what he is upset about will not give the patient time to cry and express his emotions. DIF: Cognitive Level: Applying (Application) REF: p. 5 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. During an interview, you have the impression that a patient may be considering suicide.

Which action is essential? a. Ask whether the patient has considered self-harm. b. Avoid directly confronting the patient regarding your impression. c. Ask whether the patient would like to visit a psychiatrist. d. Record the impression in the patient’s chart and refer the patient for hospitalization. ANS: A

If you think the patient may be considering suicide, he or she probably is. Mentioning it gives permission to talk about it. Do not avoid directly confronting the patient regarding your impression. It is important to confront the suicidal thoughts. Asking whether the patient would like to visit a psychiatrist does not allow the patient to talk about the suicidal thoughts before you determine that she or he needs a specialist level of care. Recording the impression in the patient’s chart and referring the patient for hospitalization does not collaborate with the patient and does not give him or her permission to talk about the thoughts of self-harm. DIF: Cognitive Level: Applying (Application) REF: p. 5 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. During a history-taking session, Mr. B appears to be avoiding certain questions. He keeps

looking out the window. What should the caregiver do? a. Ask direct questions and insist on a “yes” or “no” answer to each question. b. Continue to ask questions until Mr. B responds appropriately. c. Make a note to pursue sensitive issues later in the interview. d. Stop the interview until the patient is ready to cooperate. ANS: C

When the patient dissembles, do not push too hard for an answer. Allow the interview to go on and come back to the questions he avoided answering later. Yes or no questions will close the interview process. Continue with the interview, making a note to return to questioning about that issue later in the interview. Continuing to ask questions until Mr. B responds appropriately will not allow the patient time to reflect and answer. Stopping the interview until the patient is ready to cooperate will stop the flow of communication. DIF: Cognitive Level: Applying (Application) REF: p. 5 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. You are collecting a history from an 11-year-old girl. Her mother is sitting next to her in the

examination room. When collecting history from older children or adolescents, they should be:

a. given the opportunity to be interviewed without the parent at some point during the

interview. b. mailed a questionnaire in advance to avoid the need for them to talk. c. ignored while you address all questions to the parent. d. allowed to direct the flow of the interview. ANS: A

The older child should be given the opportunity to give information directly. This enhances the probability that the child will follow your advice. Mailing a questionnaire in advance to avoid the need for her to talk does not assist the child in learning to respond to answers regarding her health. The parent can help fill in gaps at the end. If she is ignored while you address all questions to the parent, the patient will feel as though she is just being discussed and is not part of the process for the health care. The health care provider should always direct the flow of the interview according to the patient’s responses. DIF: Cognitive Level: Applying (Application) REF: p. 16 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. Information that is needed during the initial interview of a pregnant woman includes all the

following except: a. the gender that the woman hopes the baby will be. b. past medical history. c. health care practices. d. the woman’s remembering (knowledge) about pregnancy. ANS: A

The initial interview for the pregnant woman should include information about her past medical history, assessment of health practices, identification of potential risk factors, and assessment of remembering (knowledge) as it affects the pregnancy. The gender of the fetus is not as important as the information about her past medical history, health care practices, and the woman’s remembering (knowledge) about her pregnancy. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 17 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. When communicating with older children and teenagers, you should be sensitive to their: a. desire for adult companionship. b. natural urge to communicate. c. need for verbal instructions. d. typical reluctance to talk. ANS: D

Adolescents are usually reluctant to talk; therefore the provider should clearly communicate a respect for confidentiality. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 16 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. When interviewing older adults, the examiner should: a. speak extremely loudly, because most older adults have significant hearing

impairment. b. provide a written questionnaire in place of an interview.

c. position himself or herself facing the patient. d. dim the lights to decrease anxiety. ANS: C

The health care provider should position himself or herself so that the older patient can see his or her face. Shouting distorts speech, dimming the lights impairs vision, and a written interview may be necessary if all else fails. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. When you suspect that your 81-year-old patient has short-term memory loss because he

cannot remember what he had for breakfast, you should: a. order a neurology consult. b. stop all of his medications. c. validate the concern with his family or caregivers. d. dismiss the finding as a normal age-related change. ANS: C

When older adults experience memory loss for recent events, consult other family members to clarify discrepancies or to fill in the gaps. You may want to consult neurology later, but to assess the memory loss, you need validation of the patient’s responses. Stopping medications will not identify the short-term memory loss. Short-term memory loss is not an age-related change. DIF: Cognitive Level: Applying (Application) REF: p. 19 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. To what extent should the patient with a physical disability or emotional disorder be involved

in providing health history information to the health professional? a. The patient should be present during information collection but should not be addressed directly. b. All information should be collected from past records and family members while the patient is in another room. c. The patient should be involved only when you sense that he or she may feel ignored. d. The patient should be fully involved to the limit of his or her ability. ANS: D

Patients who are disabled may not give an effective history, but they must be respected, and the history must be obtained from them to the greatest extent possible. Patients should be addressed directly and participate in the interview to the extent of their ability. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 20 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. A brief statement of the reason the patient is seeking health care is called the: a. medical history. b. chief complaint. c. assessment. d. diagnosis.

ANS: B

The chief complaint is a brief statement of why the patient is seeking health care. The medical history, assessment, and diagnosis are not the reasons that the patient is seeking health care. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 10 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 29. A pedigree diagram is drafted for the purpose of obtaining: a. sexual orientation and history. b. growth and developmental status. c. genetic and familial health problems. d. ethnic and cultural backgrounds. ANS: C

A pedigree diagram, or genogram, shows consanguinity of health problems. Sexual orientation and history are noted in the review of systems (ROS). Growth and development are plotted on a percentile chart. Ethnic and cultural backgrounds are noted in the family history. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 12 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 30. When taking a history, you should: a. ask the patient to give you any information they can recall about their health. b. start the interview with the patient’s family history. c. use a chronologic and sequential framework. d. use a holistic and eclectic structure. ANS: C

To give structure to the present problem or chief complaint, the provider should proceed in a chronologic and sequential framework. Asking patients to give you any information they can recall about their health and using a holistic and electric structure do not provide structure to the history. Gathering the patient’s family history is only the first step. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 11 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 31. When questioning the patient regarding his or her sexual history, which question should be

asked initially? a. “Do you have any particular sexual likes or dislikes?” b. “Do you have any worries or concerns regarding your sex life?” c. “How often do you have intercourse and with whom?” d. “Do you have any reason to think you may have been exposed to a sexually transmitted infection?” ANS: B

When approaching questioning about a sensitive area, it is recommended that the provider first ask open-ended questions that explore the patient’s feelings about the issue. “Do you have any particular sexual likes or dislikes?” is not a question that should be asked in an interview regarding sexual history. “How often do you have intercourse and with whom?” and “Do you have any reason to think you may have been exposed to a sexually transmitted infection?” are not questions that should be asked initially in an interview regarding the patient’s sexual history. DIF: Cognitive Level: Applying (Application) REF: p. 10 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 32. A guideline for history taking is for caregivers to: a. ask direct questions before open-ended questions so that data move from simple to

complex. b. ask for a complete history at once so that data are not forgotten between meetings. c. make notes sparingly so that the patient can be observed during the history taking. d. write detailed information as stated by patients so that their priorities are reflected. ANS: C

During the interview, you should maintain eye contact with the patient, observing body language and proceeding from open-ended to direct questions. Asking direct questions first may upset the patient. During the interview you should gather as much information as you need for the current reason the patient is seeking health care. It is important to focus on the patient. Brief notes can be charted, but you should maintain eye contact with the patient, observing body language and proceeding from open-ended to direct questions. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 33. Mr. D complains of a headache. During the history, he mentions his use of alcohol and illicit

drugs. This information would most likely belong in the: a. chief complaint. b. past medical history. c. personal and social history. d. review of systems. ANS: C

Habits are included within the personal and social history. The chief complaint is the reason the patient is seeking health care. The past medical history is made up of the previous medical conditions that the patient has had. The review of systems is an overview of problems with other body systems. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 12 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 34. Direct questioning about domestic violence in the home should be: a. a routine component of history taking with female patients. b. avoided for fear of offending the woman’s partner. c. conducted only in cases in which there is a history of abuse. d. used only when the patient is obviously being victimized. ANS: A

The presence of domestic violence should be routinely queried, and the questioning should be direct for all female patients. Direct questioning about domestic violence in the home should not be avoided for fear of offending the woman’s partner, should be part of a routine examination, and should not be used only when the patient is obviously being victimized. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 9 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 35. Mrs. G reports an increase in her alcohol intake over the past 5 years. To screen her for

problem drinking, you would use the: a. CAGE questionnaire. b. PACES assessment. c. Miller Analogies Test. d. Glasgow Coma Scale. ANS: A

The CAGE questionnaire is a model for approaching a discussion of the use of alcohol. PACES is used to screen adolescents for important issues in their life. The Miller Analogies Test is used is used to test cognitive functioning. The Glasgow Coma Scale is a neurology assessment. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 8 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 36. A tool used to screen adolescents for alcoholism is the: a. CAGE. b. CRAFFT. c. PACES. d. HITS. ANS: B

The CRAFFT tool is used to screen for alcoholism in adolescents. The CAGE test is used to screen for alcoholism in adults. PACES is used to screen adolescents for important issues in their life. HITS is the screen for domestic violence. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 8 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 37. When you enter the examination room of a 3-year-old girl, you find her sitting on her father’s

lap. She turns away from you when you greet her. Initially, your best response is to: a. leave the child sitting in the father’s lap while you talk to the father. b. ask the child to be seated on the examination table so that you can talk to her father. c. explain to the child that you will not hurt her and that she will have to trust you. d. ask the father to persuade the child to cooperate with you. ANS: A

Interaction with children must be modified according to the child’s age and in a manner that promotes trust. DIF: Cognitive Level: Applying (Application) REF: p. 14 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

38. Tom is a 16-year-old diabetic who does not follow his diet. He enjoys his dirt bike and seems

unconcerned about any consequences of his activities. Which factor is typical of adolescence and pertinent to Tom’s health? a. Attachment to parents b. High self-esteem c. Low peer support needs d. Propensity for risk taking ANS: D

Adolescents tend to experiment with risky behaviors that can lead to a high incidence of morbidity and mortality. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 16 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 39. Pain is difficult to assess in older adults because: a. drugs act more rapidly with age. b. their language skills decline. c. they tend to exaggerate symptoms. d. sharp pain may be felt as a dull ache. ANS: D

Pain is often an unreliable symptom in older adults because they lose pain perception and experience pain in a different manner than those of other age groups. Older adults tend to think pain in aging is normal. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 19 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 40. Mr. Mills is a 55-year-old patient who presents to the office for an initial visit for health

promotion. A survey of mobility and activities of daily living (ADLs) is part of a(n): a. ethnic assessment. b. functional assessment. c. genetic examination. d. social history. ANS: B

A functional assessment is an assessment of a patient’s mobility, upper extremity movement, household management, ADLs, and instrumental activities of daily living (IADLs). DIF: Cognitive Level: Remembering (Knowledge) REF: p. 19 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 41. Constitutional symptoms in the ROS refer to: a. height, weight, and body mass index. b. fever, chills, fatigue, and malaise. c. hearing loss, tinnitus, and diplopia. d. rashes, skin turgor, and temperature. ANS: B

General constitutional symptoms refer to fever, chills, malaise, fatigability, night sweats, sleep patterns, and weight (average, preferred, present, change). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 13 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 42. JM has been seen in your clinic for 5 years. She presents today with signs and symptoms of

acute sinusitis. The type of history that is warranted is a(n) _________ history. a. complete b. inventory c. problem or focused d. interim ANS: C

If the patient is well known, or if you have been seeing the patient for the same problem over time, a focused history is appropriate. A complete history is only obtained during initial visits or during a complete history and physical examination (H&P). An inventory is related to but does not replace the complete history. It touches on the major points without going into detail. This is useful when the entire history taking will be completed in more than one session. An interim history is only obtained during a return of the patient after several months of absence. DIF: Cognitive Level: Applying (Application) REF: p. 20 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which of the following are connection types of communication? (Select all that apply.) a. Poor self image b. Good eye contact c. Avoiding being judgmental d. Ensuring good lighting e. Respecting silence f. Ensure confidentiality ANS: B, C, E

Poor self-image, ensuring good lighting, and ensuring confidentiality are not connection types of communications; good eye contact, avoiding being judgmental, and respecting silence are connections to communication. DIF: Cognitive Level: Applying (Application) REF: p. 3 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 02: Cultural Competency Test Bank—Nursing MULTIPLE CHOICE 1. Mr. Sanchez is a 45-year-old gentleman who has presented to the office for a physical

examination to establish a new primary care health care provider. Which of the following describes a physical, not a cultural, differentiator? a. Race b. Rite c. Ritual d. Norm ANS: A

Race is a physical, not a cultural, differentiator. Rite is a prescribed, formal, customary observance. Ritual is a stereotypic behavior regulating religious, social, and professional behaviors. A norm is a prescribed standard of allowable behavior within a group. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 22 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Which statement is true regarding the relationship of physical characteristics and culture? a. Physical characteristics should be used to identify members of cultural groups. b. There is a difference between distinguishing cultural characteristics and

distinguishing physical characteristics. c. To be a member of a specific culture, an individual must have certain identifiable physical characteristics. d. Gender and race are the two essential physical characteristics used to identify cultural groups. ANS: B

Physical characteristics are not used to identify cultural groups; there is a difference between the two, and they are considered separately. Physical characteristics should not be used to identify members of cultural groups. To be a member of a specific culture, an individual does not need to have certain identifiable physical characteristics. You should not confuse physical characteristics with cultural characteristics. Gender and race are physical characteristics, not cultural characteristics, and are not used to identify cultural groups. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 22 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. An image of any group that rejects its potential for originality or individuality is known as

a(n): a. acculturation. b. norm. c. stereotype. d. ethnos. ANS: C

A fixed image of any group that rejects its potential for originality or individuality is the definition of stereotype. Acculturation is the process of adopting another culture’s behaviors. A norm is a standard of allowable behavior within a group. Ethnos implies the same race or nationality. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 22 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. Mr. L presents to the clinic with severe groin pain and a history of kidney stones. Mr. L’s son

tells you that for religious reasons, his father wishes to keep any stone that is passed into the urine filter that he has been using. What is your most appropriate response? a. “With your father’s permission, we will examine the stone and request that it be returned to him.” b. “The stone must be sent to the lab for examination and therefore cannot be kept.” c. “We cannot let him keep his stone because it violates our infection control policy.” d. “We don’t know yet if your father has another kidney stone, so we must analyze this one.” ANS: A

We should be willing to modify the delivery of health care in a manner that is respectful and in keeping with the patient’s cultural background. “With your father’s permission, we will examine the stone and request that it be returned to him” is the most appropriate response. “The stone must be sent to the lab for examination and therefore cannot be kept” and “We don’t know yet if your father has another kidney stone, so we must analyze this one” do not support the patient’s request. “We cannot let him keep his stone because it violates our infection control policy” does not provide a reason that it would violate an infection control policy. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The motivation of the health care professional to “want to” engage in the process of becoming

culturally competent, not “have to,” is called: a. cultural knowledge. b. cultural awareness c. cultural desire d. cultural skill. ANS: C

Cultural encounters are the continuous process of interacting with patients from culturally diverse backgrounds to validate, refine, or modify existing values, beliefs, and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge. Cultural awareness is deliberate self-examination and in-depth exploration of one's biases, stereotypes, prejudices, assumptions and “-isms” that one holds about individuals and groups who are different from them. Cultural knowledge is the process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups. Cultural skill is the ability to collect culturally relevant data regarding the patient's presenting problem, as well as accurately performing a culturally based physical assessment in a culturally sensitive manner. Cultural desire is the motivation of the health care professional to want to engage in the process of becoming culturally competent, not have to.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 22 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Mr. Abdul is a 40-year-old Middle Eastern man who presents to the office for a first visit with

the complaint of new abdominal pain. You are concerned about violating a cultural prohibition when you prepare to do his rectal examination. The best tactic would be to: a. forego the examination for fear of violating cultural norms. b. ask a colleague from the same geographic area if this examination is acceptable. c. inform the patient of the reason for the examination and ask if it is acceptable to him. d. refer the patient to a provider more knowledgeable about cultural differences. ANS: C

Asking, if you are not sure, is far better than making a damaging mistake. Not completing the examination could cause the patient further harm. Asking a colleague from the same geographic area if this examination is acceptable may not be appropriate. Referring the patient to a provider more knowledgeable about cultural differences at this point is unnecessary. DIF: Cognitive Level: Applying (Application) REF: p. 24 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. Which statement is true regarding the impoverished? a. The morbidity and mortality rates of the impoverished are similar to those of the

middle class. b. The morbidity and mortality rates of the impoverished are higher than those of the

middle class. c. The morbidity and mortality rates of the impoverished are lower than those of the

middle class. d. No reliable statistics exist regarding the relationship of poverty to morbidity and

mortality. ANS: B

The morbidity and mortality rates of the impoverished are higher than those of the middle class. The poorly educated and those in poverty die at higher rates than those who are advantaged; the same is true for morbidity. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 23 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. The root of social, political, and economic tragedy is often: a. acceptance of acculturation. b. cultural attitudes. c. cultural translation. d. resistance to change. ANS: D

To protect and maintain our sociopolitical culture, we tend to resist change. This resistance can have negative sociopolitical and economic consequences. Acceptance of acculturation is the process whereby an individual accommodates to the traits of another culture. Cultural attitudes are often vague; however, they do not cause social, political, or economic tragedy. Cultural translation describes a cultural barrier that exists without a language barrier.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 24 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic.

Which question has the most potential for exploring a patient’s cultural beliefs related to a health problem? a. “How often do you have medical examinations?” b. “What is your age, race, and educational level?” c. “What types of symptoms have you been having?” d. “Why do you think you are having these symptoms?” ANS: D

“Why do you think you are having these symptoms?” is an open-ended question that avoids stereotyping, is sensitive and respectful toward the individual, and allows for cultural data to be exchanged. The other questions do not explore the patient’s cultural beliefs about health problems. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. The definition of ill or sick is based on a: a. stereotype. b. cultural behavior. c. belief system. d. cultural attitude. ANS: C

The definition of ill or sick is based on the individual’s belief system and is determined in large part by his or her enculturation. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 24 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Mr. Jones is a 45-year-old patient who presents to the office. A person’s definition of illness is

likely to be most influenced by: a. race. b. socioeconomic class. c. enculturation. d. age group. ANS: C

The definition of illness is determined in large part by the individual’s enculturation (the process whereby an individual assumes the traits and behaviors of a given culture). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 24 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. As the health care provider, you are informing a patient that he or she has a terminal illness.

This discussion is most likely to be discouraged in which cultural group? a. Navajo Native Americans b. Dominant Americans c. First-generation African descendants

d. First-generation European descendants ANS: A

The Navajo culture believes that thought and language have the power to shape reality; the desire to avoid discussing negative information is particularly strong in this culture. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. A 22-year-old female nurse is interviewing an 86-year-old male patient. The patient avoids

eye contact and answers questions only by saying, “Yeah,” “No,” or “I guess so.” Which of the following is appropriate for the interviewer to say or ask? a. “We will be able to communicate better if you look at me.” b. “It’s hard for me to gather useful information because your answers are so short.” c. “Are you uncomfortable talking with me?” d. “Does your religion make it hard for you to answer my questions?” ANS: C

It is all right to ask if the patient is uncomfortable with any aspect of your person and to talk about it; the other choices are less respectful. DIF: Cognitive Level: Applying (Application) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. As you explain your patient’s condition to her husband, you notice that he is leaning toward

you and pointedly blinking his eyes. Knowing that he is from England, your most appropriate response to this behavior is to: a. tell him that you understand his need to be alone. b. ask whether he has any questions. c. ask whether he would prefer to speak to the clinician. d. tell him that it is all right to be angry. ANS: B

The English worry about being overheard and tend to speak in modulated voices so, when they lean in toward you, they are probably poised to ask a question. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. An aspect of traditional Western medicine that may be troublesome to many Hispanics, Native

Americans, Asians, and Arabs is Western medicine’s attempts to: a. use a holistic approach that views a particular medical problem as part of a bigger picture. b. determine a specific cause for every problem in a precise way. c. establish harmony between a person and the entire cosmos. d. restore balance in an individual’s life. ANS: B

A more scientific approach to health care problem solving, in which a cause can be determined for every problem in a precise way, is a Western approach. Hispanics, Native Americans, Asians, and Arabs embrace a more holistic approach. Using a holistic approach, establishing harmony between a person and the entire cosmos, and restoring balance in an individual’s life would not be troublesome to many Hispanics, Native Americans, Asians, and Arabs. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. In a naturalistic or holistic approach to health, an example of a hot symptom would be: a. diarrhea. b. an earache. c. a headache. d. a nasal cold. ANS: A

A hot symptom in cultures with a holistic approach is diarrhea. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. An example of a cold condition would be: a. a fever. b. a rash. c. tuberculosis. d. an ulcer. ANS: C

A cold condition in cultures with a holistic approach is tuberculosis. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. An example of a cold food is: a. cod. b. eggs. c. oil. d. onions. ANS: A

Cod is a cold food. Eggs, oil, and onions are hot foods. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. Penicillin is considered a: a. cold herb. b. cold medicine. c. hot medicine. d. lukewarm oil.

ANS: C

Penicillin is an example of a hot medicine. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 26 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. Because of common cultural food preferences, avoidance of monosodium glutamate (MSG) is

likely to be most problematic for the hypertensive patient of which group? a. Native Americans b. Hispanics c. Chinese d. Italians ANS: C

The Chinese are most likely to use MSG and soy sauce in their diet. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 28 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. Which maternal factor is most predictive of whether an infant will receive inoculations? a. Mother has family support b. Mother is divorced c. Mother received prenatal care d. Mother uses drugs ANS: C

Mothers who take advantage of appropriate prenatal care generally take advantage of other infant care practices. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 28 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. Which adolescents are most likely to engage in risky behaviors? a. Those who spend large amounts of time watching television and listening to heavy

metal music b. Those who represent minority races and/or cultural groups c. Females who represent minority groups d. Those who are of lower socioeconomic status because of limited parental education ANS: A

Adolescents who spend a lot of time watching television and listening to heavy metal music are more likely than any other group to engage in risky behaviors regardless of race, gender, or parents’ education. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 28 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. Adolescents most likely to smoke, abuse substances, perform poorly in school, and be

depressed are those who are: a. from dual-income families. b. from families that emphasize strong religious beliefs.

c. from deprived socioeconomic groups. d. unsupervised after school. ANS: D

Adolescents who are unsupervised after school are more likely to smoke, abuse substances, perform poorly in school, and be depressed than adolescents in any other situation. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 28 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. Knowledge of the culture(s) represented by the patient should be used to: a. form a sense of the patient. b. help make the interview questions more pertinent. c. form stereotypical categories. d. draw conclusions regarding individual patient needs. ANS: B

The purpose of understanding the patient’s culture(s) is to help the provider construct pertinent questions and avoid stereotyping. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 27 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. The attitudes of the health care professional: a. are largely irrelevant to the success of relationships with the patient. b. do not influence patient behavior. c. are difficult for the patient to sense. d. are culturally derived. ANS: D

The attitudes of the health care provider are foundationally derived from his or her own culture; understanding this is relevant to the success of patient relationships. Attitudes of the health care professional are easily detected by others, and they influence patient behavior; they are not irrelevant to the success of relationships with the patient; they do influence patient behavior; and they are not difficult for the patient to sense. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 29 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which of the following variables can intrude on successful communication? (Select all that

apply.) a. Social class b. Gender c. Stereotype d. Phenotype e. Age ANS: A, B, E

Social class, age, and gender are variables that characterize everyone; they can intrude on successful communication if there is no effort for mutual knowledge and understanding.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 24 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation SHORT ANSWER 1. In terms of cultural communication differences, Americans are more likely to _____________

than are other groups of patients. ANS:

come quickly to the point In the United States, individuals are very direct in conversation and come to the point quickly. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 29 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 03: Examination Techniques and Equipment Test Bank—Nursing MULTIPLE CHOICE 1. Guidelines for Standard Precautions indicate that mask and eye protection or a face mask

should be used while performing: a. tube feedings. b. patient bathing. c. wet to dry dressing changes. d. trachea care and suctioning. ANS: D

Use of masks and eye protection or a face mask is indicated during procedures that are likely to generate splashes or sprays of body fluids, which include endotracheal secretions. During tube feedings, patient bathing, and wet to dry dressing changes, there is no splashing of body fluids. DIF: Cognitive Level: Applying (Application) REF: p. 30 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Standard Precautions apply: a. only to patients with bloodborne infections. b. only to patients with infected, draining wounds. c. only to patients believed to have an infectious disease. d. to all patients receiving care in hospitals. ANS: D

Standard Precautions were developed with the intent of application to the care of all hospitalized patients; however, the standard has merit to be applied to all cases of patient care, regardless of the environment in which care is delivered. Standard Precautions apply to all patients, not just those with bloodborne infections, infected, draining wounds, or those believed to have an infectious disease. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 31 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. According to the guidelines for Standard Precautions, the caregiver’s hands should be washed: a. only after touching body fluids with ungloved hands and between patient contacts. b. only after touching blood products with ungloved hands and after caring for

infectious patients. c. only after working with patients who are thought to be infectious. d. after touching any body fluids or contaminated items, regardless of whether gloves

are worn. ANS: D

Hand washing is to be done after removal of gloves, between patient contacts, and after touching body fluids, regardless of whether gloves are used. The nurse should never touch body fluids or blood products with ungloved hands. The nurse should use hand hygiene regardless of a patient’s possible infection.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 31 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. Which patient is at the highest risk for developing latex allergy? a. The new patient who has no chronic illness and has never been hospitalized b. The patient who has had multiple procedures or surgeries c. The patient who is a vegetarian d. The patient who is allergic to contrast dye ANS: B

The patient who has had multiple procedures or surgeries has a higher rate of exposure to rubber gloves and to equipment and supplies that contain latex and therefore is at a higher risk for developing an allergic response. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 30 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. One recommendation to prevent latex allergy is to: a. wear latex gloves frequently to reduce sensitivity. b. use oil-based creams or lotions before donning gloves. c. wash hands with mild soap after removing gloves and then dry thoroughly. d. use well-powdered gloves with increased protein content. ANS: C

The recommendations are to use nonlatex gloves for situations not likely to involve infectious materials, not to use oil-based creams or lotions, wash hands with mild soap and dry thoroughly after removing gloves, or use powder-free latex gloves with reduced protein content. DIF: Cognitive Level: Applying (Application) REF: p. 30 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Mr. Walder is a 56-year-old man who has been complaining of chest palpitations. Which

position is useful for auscultating heart sounds? a. Prone b. Dorsal recumbent c. Left lateral recumbent d. Right Sims ANS: C

The left lateral recumbent position places the left ventricle closer to the chest wall and is recommended for auscultating low-pitched sounds, such as the third and fourth heart sounds. If the patient is in the prone, dorsal recumbent, or right Sims position, you will not be able to auscultate heart sounds. The dorsal recumbent position is for examination of the rectum and genitalia. The Sims position is the position for examination of the rectum. DIF: Cognitive Level: Applying (Application) REF: p. 32 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. Which technique is used during both the history taking and the physical examination process? a. Auscultation

b. Inspection c. Palpation d. Percussion ANS: B

Inspection is the technique that is used while gathering and validating data during both the history taking and the actual hands-on physical examination. Auscultation, palpation, and percussion are not used during the history taking and physical examination processes. It is not possible to listen to the patient talking and use the stethoscope at the same time. The focus is on the patient’s response to your touch and what you are feeling; it is not possible to perform palpation and listen to the patient talking at the same time. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 32 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Ms. Jones is a 31-year-old female patient who presents for a routine physical examination.

Which examination technique will be used first? a. Light palpation b. Deep palpation c. Percussion d. Inspection ANS: D

Inspection, the process of systematic observation, is the first technique used in an examination. Light palpation is used after inspection. The order for examination is usually inspection, palpation, percussion, and then auscultation. Deep palpation is used after inspection. Percussion is used after inspection and palpation. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 32 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. The use of secondary, tangential lighting is most helpful in the detection of: a. variations in skin color. b. enlarged tonsils. c. foreign objects in the nose or ear. d. variations in contour of the body surface. ANS: D

Tangential lighting is used to cast shadows to observe contours and variations in body surfaces best. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 33 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. You are caring for a nonambulatory 80-year-old male patient and he tells you, a female nurse,

that he feels like he is having drainage from his rectum. Which initial nursing action is appropriate? a. Drape the patient and observe the rectal area. b. Tell the patient that his doctor will be notified of his problem. c. Tell the patient that you will ask the male nurse on the next shift to check on the problem. d. Give the patient an ice pack to apply to the area.

ANS: A

Necessary exposure for direct observation, while adjusting for modesty, is warranted. The complaint warrants validation before referral or delegation. Before you call the physician, you need to assess the patient. The assessment should not wait for another shift. Before treatment, it is important to assess the complaint. DIF: Cognitive Level: Applying (Application) REF: p. 32 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Mrs. Smalls is a 42-year-old woman who has presented to the office for a head to toe

examination as part of her preventive health care assessment. The room has adequate lighting, and you have access to both sides of the examining table. What position should you assume while conducting this examination? a. Behind the patient b. Either side of the patient c. Seated in a chair in front of the patient d. To the right side of the patient ANS: B

Although examiners are conventionally taught to approach an examination from the patient’s right side, it is not always practical; therefore the most appropriate response is that the examiner should develop skills necessary to approach either side of the patient. If you approach the patient from behind, you will not have access to the anterior areas for assessment. If you are seated, you will not be able to assess all areas of the patient. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 33 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. You are planning to palpate the abdomen of your patient. Which part of the examiner’s hand is

best for palpating vibration? a. Dorsal surface b. Finger pads c. Fingertips d. Ulnar surface ANS: D

The ulnar surface of the hand and bases of the fingers can best feel vibratory sensations such as thrills and fremitus. The dorsal surface of the hand is best for assessing temperature. The finger pads and fingertips are best for palpating pulses. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 33 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. The dorsal surface of the hand is most often used for the assessment of: a. crepitus. b. temperature. c. texture. d. vibration. ANS: B

The dorsal surface, or back of the hand, is best for assessing warmth, or temperature. The palmar surface, rather than the dorsal surface, is best for assessing crepitus. The palmar surface, rather than the dorsal surface, is best for assessing texture. The ulnar surfaces of the hand and fingers, rather than the dorsal surface, are best for assessing vibration. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 33 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal

pain. You have completed the inspection of the abdomen. What is your next step in the assessment process? a. Light palpation b. Deep palpation c. Percussion d. Auscultation ANS: D

Auscultation precedes palpation or percussion of the abdomen because these techniques can stimulate peristalsis, which may alter correct assessment of the abdominal sounds. Light palpation, deep palpation, and percussion should not be completed until auscultation is completed. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 35 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. The degree of percussion tone is determined by the density of the medium through which the

sound waves travel. Which statement is true regarding the relationship between density of the medium and percussion tone? a. The more dense the medium, the louder is the percussion tone. b. The less dense the medium, the louder is the percussion tone. c. The more hollow the area percussed, the quieter is the percussion tone. d. Percussion over muscle areas produces the loudest percussion tones. ANS: B

Percussion sounds vary according to the tissue being percussed. Less dense tissue (such as that over normal lungs) produces a loud tone, whereas more dense tissue (such as a muscle) produces a softer tone. The more dense the medium, the softer is the percussion tone. The more hollow the area, the louder is the percussion tone. Percussion tones over muscle are soft and flat. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 34 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. Expected normal percussion tones include: a. dullness over the lungs. b. hyperresonance over the lungs. c. tympany over an empty stomach. d. flatness over an empty stomach. ANS: C

A normal lung produces resonance percussion tones, whereas an empty stomach is expected to produce tympany. Dullness indicates atelectasis of the lung. Hyperresonance over the lungs indicates emphysema. Flatness occurs over muscle. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 34 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. During percussion, a dull tone is expected to be heard over: a. healthy lung tissue. b. emphysemic lungs. c. the liver. d. most of the abdomen. ANS: C

Dull tones are expected over denser areas such as the liver. Healthy lung tissue is resonant. Emphysemic lungs are hyperresonant. Tympany is heard over most of the abdomen. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 34 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. When using mediate or indirect percussion, which technique is appropriate? a. Place the palmar surface of the nondominant hand on the body surface, with the

fingers held together. b. Place the palmar surface of the nondominant hand on the body surface, with the

fingers slightly spread apart. c. Place the ulnar surface of the nondominant hand on the body surface, with the

fingers together. d. Place the ulnar surface of the nondominant hand on the body surface, with the

fingers slightly spread apart. ANS: B

The palmar surface of the nondominant (stationary) hand should rest against the body surface, with the fingers spread slightly. A helpful tip to improve elicitation of correct tones is to hyperextend the middle finger of the stationary hand and place the distal interphalangeal joint firmly against the body surface. This lifting of the fingertip avoids dampening of the vibratory sounds. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 34 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. During percussion, the downward snap of the striking fingers should originate from the: a. shoulder. b. forearm. c. wrist. d. interphalangeal joint. ANS: C

The downward snap of the striking fingers should originate from the wrist. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 34 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. Which technique is commonly used to elicit tenderness arising from the liver, gallbladder, or

kidneys? a. Finger percussion b. Palmar percussion c. Fist percussion d. Forearm percussion ANS: C

Fist percussion is a direct percussion technique used to elicit tenderness over organs such as the liver, gallbladder, or kidneys. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 34 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. During auscultation, you can limit your perceptual field best by: a. asking patients to describe their symptoms. b. closing your eyes. c. performing auscultation before percussion. d. using an aneroid manometer. ANS: B

By closing your eyes, your sense of hearing becomes more acute, and it increases your ability to isolate sounds. Asking patients to describe their symptoms does not assist in the technique of auscultation. The only time that auscultation occurs before percussion is in examination of the abdomen. Using an aneroid manometer does not assist in the technique of auscultation. During auscultation, the only equipment needed is the stethoscope. DIF: Cognitive Level: Applying (Application) REF: p. 35 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. You are auscultating a patient’s chest. The sounds are not clear, and you are having difficulty

distinguishing between respirations and heartbeats. Which technique can you use to facilitate your assessment? a. Anticipate the next sounds. b. Isolate each cycle segment. c. Listen to all sounds together. d. Move the stethoscope clockwise. ANS: B

If you are hearing everything at once, it is more difficult to distinguish different sounds. Try isolating each segment and listen to that segment intently; then move on to another segment. For example, listen only to breath sounds, then only to inspiratory breath sounds, and then only to expiratory breath sounds. Anticipating the next sounds will not facilitate the assessment. Listening to all sounds together will not facilitate the assessment. One of the most difficult achievements in auscultation is learning to isolate sounds. Moving the stethoscope clockwise will not facilitate the assessment. DIF: Cognitive Level: Applying (Application) REF: p. 35 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. Auscultation should be carried out last, except when examining the: a. neck area.

b. heart. c. lungs. d. abdomen. ANS: D

Auscultation is the last examination technique used for all areas except the abdomen. In this case, it is performed after inspection. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 35 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. Tympanic thermometers measure body temperature when a probe is placed: a. anterior to the ear. b. posterior to the ear. c. under the ear. d. in the auditory canal. ANS: D

Tympanic thermometer probes are placed at the external opening of the auditory canal. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 38 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. A scale used to assess patients’ weight should be calibrated: a. only by the manufacturer. b. by a qualified technician at regularly scheduled intervals. c. each time it is used. d. when necessary, with the patient standing on the scale. ANS: C

Obtaining weight begins with a manual calibration of the scale before the patient stands on the scale. Electronic scales are automatically calibrated before each reading. The manufacturer does not calibrate the scale after it is sold. A qualified technician does not calibrate the scale at regularly scheduled intervals. Scales cannot be calibrated with the patient standing on the scale. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 37 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. The height-measuring attachment of the standing platform scale should be pulled up: a. before the patient steps on the scale. b. before the scale is balanced. c. after the patient steps on the scale. d. only after weight has been assessed. ANS: A

To ensure patient safety, the arm of the height-measuring attachment should be pulled up before the patient steps on the scale, after the scale is balanced, and before weight is assessed. DIF: Cognitive Level: Applying (Application) REF: p. 37 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

27. The infant should be placed in which position to have his or her height or length measured? a. Vertically, with the examiner’s hands under the infant’s axillae b. Supine on a measuring board c. Prone on a measuring board d. In the lateral position, with the toes against a measuring board ANS: B

The infant should be placed supine on a measuring board to measure height or length. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 37 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. Which of the following occurs when firm pressure is used to apply the stethoscope’s bell

endpiece to the skin? a. It transmits low-pitched sounds. b. It functionally converts to a diaphragm endpiece. c. Assessment findings are more accurate. d. Most sounds are occluded. ANS: B

Applying firm pressure to the bell endpiece causes the skin to act as a diaphragm, obliterating the low-pitched sounds. DIF: Cognitive Level: Applying (Application) REF: p. 39 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 29. A rubber or plastic ring should be around the bell endpiece of a stethoscope to: a. prevent the transmission of static electricity. b. prevent cold metal from touching the patient. c. prevent the sharp edge of the stethoscope from damaging the patient’s skin. d. ensure secure contact with the body surface. ANS: D

The ring around the bell portion of the stethoscope secures contact with body surfaces when placed lightly on the skin. DIF: Cognitive Level: Applying (Application) REF: p. 39 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 30. Weak pulses, fetal heart activity, and vessel patency are all best assessed with which type of

stethoscope? a. Acoustic b. Electronic c. Ultrasonic d. Magnetic ANS: C

Only the ultrasonic stethoscope, the Doppler, can detect blood flow rather than amplify sounds, which is needed in assessing weak pulses, fatal heart activity, and vessel patency. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 39 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

31. You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens selector

clockwise and then counterclockwise to compensate for: a. amblyopia. b. astigmatism. c. myopia. d. strabismus. ANS: C

Rotating the lens selector compensates for myopia (nearsightedness) or hyperopia (farsightedness) in the examiner and patient. DIF: Cognitive Level: Applying (Application) REF: p. 42 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 32. A patient in the emergency department has a concussion. You suspect the patient may also

have a retinal hemorrhage. You are using the ophthalmoscope to examine the retina of this patient. Which aperture of the ophthalmoscope is most appropriate for this patient? a. Grid b. Red-free filter c. Slit lamp d. Small aperture ANS: B

The red-free filter permits recognition of hemorrhages. The grid estimates the size of lesions, the slit lamp examines the anterior eye and assesses the elevation of lesions, and the small aperture is used with small pupils. DIF: Cognitive Level: Applying (Application) REF: p. 42 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 33. Which type of speculum should be used to examine a patient’s tympanic membrane? a. The smallest speculum that will illuminate the ear b. The largest speculum that will fit comfortably in the ear c. The shortest speculum available d. Any speculum that will fit the otoscope head ANS: B

To visualize the tympanic membrane adequately, the largest speculum that can comfortably fit in the ear canal should be used. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 45 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 34. The pneumatic attachment for the otoscope is used to evaluate: a. ear canal patency. b. eardrum landmarks. c. hearing acuity. d. tympanic membrane movement. ANS: D

The pneumatic attachment on the otoscope produces a puff of air directed to the tympanic membrane, resulting in its movement. The pneumatic attachment for the otoscope is not used to evaluate ear canal patency, eardrum landmarks, or hearing acuity. Ear canal patency is assessed by visually inspecting the ear. Hearing acuity is assessed by the whisper test. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 45 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 35. Mr. Walters, a 32-year-old patient, tells you that his ears are “stopped up.” An objective

assessment of this complaint is achieved by using the: a. tuning fork. b. reflex hammer. c. otoscope with pneumatic attachment. d. tympanometer. ANS: D

This patient is describing eustachian tube dysfunction. The tympanometer measures compliance of the middle ear as air pressures are varied. It is an objective means of assessing the function of the ossicular chain, eustachian tube, and tympanic membrane. The tuning fork assesses vibration. The reflex hammer assesses tendon reflexes. The otoscope with pneumatic attachment assesses tympanic membrane movement. DIF: Cognitive Level: Applying (Application) REF: p. 45 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 36. Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure: a. buzzing or tingling sensations. b. buzzing from bone conduction. c. hearing range of normal speech. d. noise above the threshold level. ANS: C

Normal speech has a range of 300 to 3000 Hz; therefore the 500- to 1000-Hz fork is used most often because it can estimate hearing loss in the range of normal speech. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 46 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 37. To perform a deep tendon reflex measurement, you should: a. briskly tap the tendon with the rubber end of the hammer. b. place the hammer firmly on the tendon for 3 to 5 seconds. c. tap the silver end of the hammer on the tendon. d. use the needle implement to determine sensory perception. ANS: A

Deep tendon reflexes are measured by quickly and firmly tapping either end of the rubber hammer on the stretched tendon and then observing muscle movement. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 46 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

38. A variant of the percussion hammer is the neurologic hammer, which is equipped with which

of the following? a. Brush and needle b. Tuning fork and cotton swab c. Penlight and goniometer d. Ruler and bell ANS: A

The neurologic hammer unscrews at the handle to reveal a soft brush, and the knob on the head unscrews to reveal an attached sharp needle. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 46 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 39. When monitoring serial measures, such as head circumference or abdominal girth, which

procedure is best to ensure that the tape measure is placed in the same position each time? a. Record the anatomic location for tape placement in the patient’s chart. b. Mark the borders of the tape at several intervals on the skin with a pen. c. Demonstrate proper tape placement to all members of the health care team. d. Ask the same person to perform the measurement each time. ANS: B

The most effective procedure to ensure correct serial measurements is to mark the borders at several intervals so that with the next measurements, the tape is in the same location. Recording the anatomic location for tape placement in the patient’s chart or demonstrating proper tape placement does not ensure accuracy. The same person may not always be available. DIF: Cognitive Level: Applying (Application) REF: p. 47 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 40. Transillumination functions on the principle that: a. air, fluid, and tissue transmit light differentially. b. black light causes certain substances to fluoresce. c. converging and diverging light brings structures into focus. d. tangential light casts shadows that illuminate contours. ANS: A

Transillumination functions to differentiate between various media in a cavity. It can distinguish among air, fluid, and tissue. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 47 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 41. When transillumination of a body cavity is performed, the use of which of the following could

be harmful to the patient? a. Penlight b. Flashlight c. Halogen bulb d. Otoscope light ANS: C

A halogen bulb can burn the skin. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 47 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 42. The Pederson speculum has blades that: a. are smaller than a plastic one. b. have an auto lock feature c. are narrower and flatter. d. only the bottom blade moves. ANS: C

The Pederson speculum has blades that are as long as those of the Graves speculum but are narrower and flatter. It is used for women with small vaginal openings. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 47 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which of the following are causes of hyperreflexia? (Select all that apply.) a. Cold stirrups b. Standard scale c. Insertion of a speculum d. Fever e. Pressure during bimanual exam ANS: A, C, E

Hyperreflexia is often caused by a cold, hard, examination table, cold stirrups, insertion or manipulation of a speculum, or pressure during bimanual or rectal examinations. DIF: Cognitive Level: Applying (Application) REF: p. 37 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation COMPLETION 1. The Snellen E vision acuity chart would most likely be used for __________. ANS:

preschool children The E chart is used for children 3 to 5 years of age or others who do not know the alphabet. The examinee is asked which way the E points. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 44 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The stethoscope’s diaphragm is most useful for the assessment of __________ sounds. ANS:

high-pitched

The diaphragm is best for hearing high-pitched sounds, such as breath sounds, bowel sounds, and normal heart tones. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 40 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. For a woman with a small vaginal opening, the examiner should use a __________ speculum. ANS:

Pederson The Pederson speculum has blades that are as long as those of the Graves speculum but are narrower and flatter and therefore more comfortable for women with small vaginal openings. Pediatric or nasal speculums would be too small for adult use. DIF: Cognitive Level: Applying (Application) REF: p. 47 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 04: Vital Signs and Pain Assessment Test Bank—Nursing MULTIPLE CHOICE 1. The pyrexia response is triggered by the production and release of: a. prostaglandins. b. endogenous pyrogens. c. hypothalamic enzymes. d. thyroid hormones. ANS: A

When microorganisms invade the body, pyrogens are released and travel to the hypothalamus. The pyrexia response is then triggered by the production and release of prostaglandins. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 50 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. During respiration, the internal intercostals: a. increase the force of muscular contraction. b. decrease the lateral diameter during expiration. c. decrease the intrathoracic space. d. increase elastic recoil during expiration. ANS: B

The diaphragm is the dominant muscle during respiration. It contracts and pushes downward during inspiration to increase the intrathoracic space. The external intercostal muscles increase the AP diameter during inspiration and the internal intercostals decrease the lateral diameter during expiration. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 50 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The fifth vital sign is: a. pain. b. orientation. c. waist-to-hip ratio. d. body mass index (BMI). ANS: A

Pain, the universal distress signal, is now recognized as the fifth vital sign. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 50 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The Joint Commission (TJC) requires that: a. pain be assessed on all discharges. b. repeated assessment of pain be limited to those patients who complain of pain. c. repeated intensity documentation be made of the course of pain relief for all

patients. d. pain be assessed on surgical patients.

ANS: C

TJC requires pain assessment on all admissions, repeated assessments for pain regardless of the initial complaint or surgical experience, and repeated intensity documentation of the course of pain relief for all patients. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 50 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The perception of pain: a. is the same across cultures. b. can be easily assessed in neonates. c. is predictable with the same circumstances. d. is affected by emotions and quality of sleep. ANS: D

The perception of pain is variable and is affected by emotions, cultural background, sleep deprivation, previous pain experience, and age. Perception of pain is different among different cultures. Neonates do feel pain, but perception of pain cannot be assessed in neonates. Each circumstance will provide different pain perception. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 51 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. The nurse assesses the blood pressure to be 140/62 mm Hg and records 78 as the: a. pulse pressure. b. pulse deficit. c. afterload. d. preload. ANS: A

Systolic pressure – diastolic pressure = pulse pressure. Pulse deficit occurs when the number of pulse beats counted at the radial pulse is less than those counted at the same time at the heart. Afterload and preload are not measured according to blood pressures. DIF: Cognitive Level: Applying (Application) REF: p. 50 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 7. Hypertension in the adult is generally defined as pressure in excess of: a. 120 mm Hg plus the patient’s age. b. 140 mm Hg. c. 160 mm Hg. d. 200 mm Hg. ANS: B

Optimal blood pressure is below 120/80 mm Hg. According to JNC7, hypertension continues to be defined as 140/90 mm Hg and higher. Prehypertension is the range between optimal and hypertension. The equation that systolic blood pressure should be less than 120 mm Hg plus the patient’s age is no longer the acceptable definition. DIF: Cognitive Level: Remembering (Knowledge)

REF: p. 54

OBJ: Nursing process—assessment

MSC: Physiologic Integrity: Reduction of Risk Potential

8. A blood pressure cuff bladder should be long enough to: a. cover 20% to 25% of the arm circumference. b. cover 45% to 50% of the arm circumference. c. cover 75% to 80% of the arm circumference. d. completely encircle the arm. ANS: C

The length of the cuff bladder should be twice its width, or about 75% to 80% of the limb circumference. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 54 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. If a sufficiently large cuff is unavailable to fit an obese arm, which technique may be used to

assess blood pressure? a. Wrap a standard cuff around the deltoid area and place the stethoscope over the radial artery. b. Wrap a standard cuff around the forearm and place the stethoscope over the radial artery. c. Wrap a standard cuff around the thigh and place the stethoscope on the dorsalis pedis. d. Wrap a pediatric cuff around the ankle and place the stethoscope on the popliteal artery. ANS: B

A technique to use when assessing the blood pressure of an obese person and you only have a standard adult cuff is to wrap the cuff around the smaller forearm, and place the stethoscope over the radial artery. This substitution should comply with the cuff standard of one third to one half of the circumference of the limb. The cuff should be wrapped around the forearm, not the deltoid or thigh areas. A pediatric cuff will not fit the ankle. DIF: Cognitive Level: Applying (Application) REF: p. 54 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Postural hypotension is defined as a ___________________ when the patient stands

compared with sitting or supine readings. a. systolic pressure drop of more than 15 mm Hg with a pulse rate increase b. pulse rate decrease with a systolic pressure increase of at least 15 mm Hg c. diastolic pressure increase of more than 5 mm Hg and no pulse rate changes d. pulse rate decrease and diastolic pressure decrease of more than 5 mm Hg ANS: A

Postural hypotension (orthostatic hypotension) represents a significant decrease in systolic pressure greater than 15 mm Hg, an accompanied drop in diastolic pressure, and a rise in pulse rate whenever the position changes from sitting to standing. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 55 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 11. The most frequent cause of serious hypertension in children is:

a. b. c. d.

heart disease. liver failure. renal disease. rheumatic fever.

ANS: C

If the systolic blood pressure is elevated and the diastolic blood pressure is not, anxiety may be responsible. Blood pressure in children varies by gender and height at any age. Hypertension in children is becoming more common because of the increased prevalence of overweight children. Usually, hypertension is caused by kidney disease, renal arterial disease, coarctation of the aorta, and pheochromocytoma, not heart disease, liver failure, or rheumatic fever. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 58 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 12. Underestimation of blood pressure will occur if the cuff’s width covers: a. less than half of the upper arm. b. less than 5 inches of the lower arm. c. more than two thirds of the upper arm. d. more than 4 inches of the lower arm. ANS: C

Cuffs that are too wide will underestimate blood pressure, which would occur with a cuff that covers more than two thirds of the upper arm. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 54 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. Your 85-year-old patient is complaining of right knee pain. She has a history of osteoarthritis,

for which she is given antiinflammatory medication. To assess her right knee pain, you should ask her if: a. the current pain is similar to previous pain. b. the left knee hurts as well. c. she took pain medication last night. d. the pain gets better when she sits. ANS: C

It is most appropriate to ask a present tense evaluation question, such as whether the patient took her pain medication; the question should be simply worded, without the addition of multiple factors to consider. You should refrain from asking older patients to compare past with present symptoms because recollection may be uncertain and recollection of past pain is sometimes not readily achieved. Systematic evaluation of the right knee should be completed before any additional symptoms are evaluated. Knowing that the pain gets better when she sits does not help assess the right knee pain. DIF: Cognitive Level: Applying (Application) REF: p. 56 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Body language that leads you to suspect that a person is in pain is: a. talkative, verbose speech. b. fretful hand movements.

c. focused, fixed eye stares. d. marked salivation. ANS: B

The person in pain may suddenly become quiet, have an inability to keep the hands still, and have lackluster eyes, pallor, diaphoresis, pupil dilation, and dry mouth. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 56 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Ms. Green is an 85-year-old female patient with dementia who presents to the emergency

department with her daughter because of a change in function. Which pain assessment scale would be the best choice? a. Oucher Scale b. Checklist for Nonverbal Pain Indicators c. Wong/Baker Rating Scale d. CRIES Scale ANS: B

The Checklist for Nonverbal Pain Indicators is for nonverbal adults. The Oucher and Wong/Baker Rating Scales are pediatric scales. The CRIES Scale is for infants. DIF: Cognitive Level: Applying (Application) REF: p. 60 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which of the following occurs with malignant hypertension? (Select all that apply.) a. Blurred vision b. Sleep disturbance c. Tachycardia d. Dyspnea e. Encephalopathy ANS: A, D, E

Signs of malignant hypertension include headache, blurred vision, dyspnea, and encephalopathy. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 62 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. In a syndrome in which regional pain extends beyond this specific peripheral nerve injury,

you would notice which of the following: (Select all that apply.) a. Allodynia b. Sleep disturbance c. Blood flow changes d. Numbness e. Edema ANS: A, C, D, E

Complex regional pain syndrome includes the following symptoms: burning shooting pain with aching character, exaggerated sensitivity to cold, allodynia, numbness, edema, blood flow changes, and temperature changes DIF: Cognitive Level: Analyzing (Analysis) REF: p. 62 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation SHORT ANSWER 1. A normal adult’s pulse pressure should range from _____ to _____ mm Hg. ANS:

30; 40 An adult’s pulse pressure should range from 30 to 40 mm Hg, and may even be as high as 50 mm Hg. Pulse pressure is the difference between the systolic and diastolic pressures. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 54 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 2. The difference in blood pressure readings between the right and the left arms is considered

normal up to ___ mm Hg. ANS:

10 Blood pressure readings between the left and right arm may vary by as much as 10 mm Hg and tend to be higher in the right arm. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 54 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 3. If only two blood pressure values are recorded, they are the _______________ sounds. ANS:

first systolic and second diastolic Phase 1 (systolic sound) and phase 5 (second diastolic sound) would be recorded if only two blood pressure values were used. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 54 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 4. You are completing an examination on a 4-year-old child. Pain scales that are reliable and

valid for children are the _____ Scales. ANS:

Wong/Baker Faces Rating and Oucher The Wong/Baker Faces Rating and Oucher Scales are examples of pain scales that are reliable and valid for use with children.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 59 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Pain is often referred to as the fifth vital sign because ____________________. ANS:

of its association with tissue damage DIF: Cognitive Level: Analyzing (Analysis) REF: p. 56 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 05: Mental Status Test Bank—Nursing MULTIPLE CHOICE 1. When is the mental status portion of the neurologic system examination performed? a. During the history-taking process b. During assessment of cranial nerves and deep tendon reflexes c. During the time when questions related to memory are asked d. Continually, throughout the entire interaction with a patient ANS: D

A mental status evaluation should be continually performed throughout the patient encounter. Assessing and validating clues to determine the individual’s ability to interact within the environment is a priority of the mental status evaluation. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 64 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. A 69-year-old truck driver presents with a sudden loss of the ability to understand spoken

language. This indicates a lesion in the: a. temporal lobe. b. Broca area. c. frontal cortex. d. cerebellum. ANS: A

The temporal lobe, specifically in the Wernicke speech area, is responsible for the comprehension of spoken and written language. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 64 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Mr. DeLaurentis is a 58-year-old man who presents to your office with slumped posture and a

lack of facial expression, which may indicate depression or: a. Parkinson disease. b. anxiety. c. loss of abstract reasoning. d. attention-deficit/hyperactivity disorder. ANS: A

A slumped posture and lack of facial expression may be clues to more than depression; they are also defining characteristics of Parkinson disease. DIF: Cognitive Level: Applying (Application) REF: p. 64 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The ability for abstract thinking normally develops during: a. infancy. b. early childhood. c. adolescence.

d. adulthood. ANS: C

Abstract thinking is an intellectual maturation that develops during adolescence. DIF: Cognitive Level: Remembering (Knowledge) REF: pp. 64-65 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The Mini-Mental State Examination (MMSE) may be used to: a. estimate cognitive changes quantitatively. b. estimate personality disorders qualitatively. c. diagnose neurologic disorders. d. determine the cause of memory loss. ANS: A

The MMSE is a standard tool that functions to estimate cognitive function quantitatively or to document cognitive changes serially. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 67 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Assessing orientation to person, place, and time helps determine: a. ability to understand analogies. b. abstract reasoning. c. attention span. d. state of consciousness. ANS: D

Orientation to person, place, and time are measures of states of consciousness and awareness. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 66 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. When you ask the patient to tell you the meaning of a proverb or metaphor, you are assessing

which of the following? a. Level of consciousness b. Abstract reasoning c. Emotional stability d. Memory ANS: B

Asking the patient to tell you the meaning of a proverb, metaphor, or fable assesses the patient’s ability to reason abstractly. Asking the patient to tell you the meaning of a proverb or metaphor does not assess level of consciousness, emotional stability, or memory. The MiniMental State Examination tests memory. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 69 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Impairment of arithmetic skills is often the result of: a. impaired execution of motor skills. b. impaired judgment.

c. perceptual distortions. d. depression. ANS: D

The patient with depression can display difficulty with simple arithmetic calculations. DIF: Cognitive Level: Applying (Application) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Peripheral neuropathy is most likely to be manifested by: a. impaired memory. b. impaired abstract reasoning. c. impaired writing ability. d. hallucinations. ANS: C

Uncoordinated writing or drawing may indicate peripheral neuropathy, dementia, parietal lobe damage, or a cerebellar lesion. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Recent memory may be tested by: a. asking the patient to name the past four presidents. b. asking the patient to listen to and repeat a series of numbers. c. showing the patient four items and asking him or her to list the items about 10

minutes later. d. asking the patient about verifiable information, such as his or her mother’s maiden name. ANS: C

Showing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Loss of immediate and recent memory with retention of remote memory suggests: a. attention-deficit/hyperactivity disorder (ADHD). b. impaired judgment. c. stupor. d. dementia. ANS: D

Dementia is the loss of both immediate and recent memory while retaining remote memories. ADHD is associated with recent and remote memory impairment. Impaired judgment is a thought process dysfunction. Stupor is impaired consciousness. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. You ask the patient to follow a series of short commands to assess: a. judgment. b. attention span. c. arithmetic calculations. d. abstract reasoning. ANS: B

Asking the patient to follow a series of short commands will test attention span. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. Which of these observations would be most significant when assessing the condition of a

patient who has judgment impairment? a. Repeated failure to complete work obligations b. Forgetting family members’ birth dates c. Going to church three times a week d. Planning for retirement in 20 years ANS: A

Inadequately dealing with business affairs indicates impaired judgment, whereas the other choices do not. DIF: Cognitive Level: Applying (Application) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Appropriateness of logic, sequence, cohesion, and relevance to topics are markers for the

assessment of: a. mood and feelings. b. attention span. c. thought process and content. d. abstract reasoning. ANS: C

Thought process and content are examined while observing the patient’s patterns of thinking, especially appropriateness of sequence, logic, coherence, and relevance to the topics discussed. DIF: Cognitive Level: Understanding (Comprehension) REF: pp. 71-72 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Which type of hallucination is most commonly associated with alcohol withdrawal? a. Olfactory b. Visual c. Auditory d. Tactile ANS: D

Tactile hallucinations are most commonly associated with alcohol withdrawal. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 72 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. Flight of ideas or loosening of associations is associated with: a. aphasia. b. dysphonia. c. multiple sclerosis. d. psychiatric disorders. ANS: D

Flight of ideas, loosening of associations, word salads, neologisms, clang associations, echolalia, and utterances of unusual sounds are all associated with psychiatric disorders. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 71 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. Facial muscle or tongue weakness may result in: a. aphasia. b. impaired comprehension. c. neologisms. d. echolalia. ANS: A

Aphasia can result from facial muscle or tongue weakness or from neurologic damage to the speech and language regions of the brain. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 71 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. The Glasgow Coma Scale is used to: a. determine the cause of decreased consciousness. b. diagnose disorders that alter level of consciousness. c. quantify consciousness. d. predict response to stimulant medications. ANS: C

The Glasgow Coma Scale is used when a patient has an altered level of consciousness and is used to quantify consciousness. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 67 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. The Denver II is a tool used to determine: a. a child’s IQ. b. a child’s mood. c. whether a child is educable. d. whether a child is developing as expected. ANS: D

Denver II is a tool used to determine whether the child is developing fine and gross motor, language, personal, and social skills as expected according to the child’s age. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 73 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. When the Goodenough-Harris Drawing Test is administered to a child, the evaluator

principally observes the: a. presence and form of body parts. b. gender and race of the person drawn. c. approximate age and posture of the person drawn. d. length of time needed to draw a stick man. ANS: A

The presence and form of body parts provide a clue about the child’s development when following the scoring criteria of the Goodenough-Harris Drawing Test. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 73 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as

indicative of: a. depression. b. cognitive impairment. c. delirium. d. dementia. ANS: D

Scores of less than 15 on this mental function test indicate dementia. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 74 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. Which condition is considered progressive rather than reversible? a. Delirium b. Dementia c. Depression d. Anxiety ANS: B

Dementia is considered progressive and irreversible. Delirium has the potential for reversal. Depression and anxiety are reversible. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 76 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. A clinical syndrome of failing memory and impairment of other intellectual functions, usually

related to obvious structural diseases of the brain, describes: a. delirium. b. dementia. c. depression. d. anxiety. ANS: B

Dementia results from a chronic progressive deterioration of the brain that results in failing memory and impairment of other intellectual functioning.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 76 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. Mrs. Griffiths, a 28-year-old patient, presents to your office to discuss her

attention-deficit/hyperactivity disorder (ADHD). Which statement is true in regard to ADHD? a. It occurs before 7 years of age. b. It is usually related to mental retardation. c. It is usually related to dementia. d. It is manifested by prolonged periods of catatonic behavior. ANS: A

ADHD occurs before 7 years of age. ADHD is not related to mental retardation, dementia, or prolonged periods of catatonic behavior. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 77 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. An aversion to touch or being held, along with delayed or absent language development, is

characteristic of: a. attention-deficit/hyperactivity disorder. b. autism. c. dementia. d. mental retardation. ANS: B

Autistic disorder involves a combination of behavioral traits (lack of awareness of others, aversion to touch or being held, odd or repetitive behaviors, or preoccupation with parts of objects) and communication deficits (usually echolalia [parrot speech]). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 78 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. You are interviewing a 20-year-old patient with a new-onset psychotic disorder. The patient is

apathetic and has disturbed thoughts and language patterns. The nurse recognizes this behavior pattern as consistent with a diagnosis of: a. depression. b. autistic disorder. c. mania. d. schizophrenia. ANS: D

Schizophrenia manifests as a psychotic disorder of early adult onset, with disturbances in language and speech, emotions and social withdrawal, and apathy. Depression and mania do not have the language or speech component. Autistic disorders are not psychotic disorders, and they usually begin before 3 years of age. DIF: Cognitive Level: Applying (Application) REF: p. 77 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. The patient who is delirious usually maintains orientation to: a. time. b. place.

c. person. d. circumstance. ANS: C

The person with delirium is unable to orient to time, place, or circumstance, but remains oriented to person. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 76 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. While interviewing a patient, you ask him to explain the “Lion and the Mouse” to assess: a. reading comprehension. b. attention span. c. mood and feeling. d. reasoning skills. ANS: D

Having the patient explain fables or metaphors determines abstract reasoning skills. DIF: Cognitive Level: Applying (Application) REF: p. 69 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 29. The Mini-Mental State Examination (MMSE) should be administered for the patient who: a. gets lost in her neighborhood. b. sleeps an excessive amount of time. c. has repetitive ritualistic behaviors. d. uses illegal hallucinogenic drugs. ANS: A

The MMSE is a tool used to quantitatively estimate cognitive function or to serially document cognitive changes. Getting lost in a familiar territory is a sign of possible cognitive impairment. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 67 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation COMPLETION 1. Under most conditions, adult patients should be able to repeat a series of _____________

numbers. ANS:

five to eight Most adults should be able to immediately recall a series of five to eight numbers forward and a series of four to six numbers backward. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The examiner should be concerned about neurologic competence if a social smile cannot be

elicited by the time a child is _________ old.

ANS:

3 months A social smile is expected in the 2- to 3-month-old infant. If it is difficult or impossible to elicit a social smile by 3 months, the infant may not be neurologically intact. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 72 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which of the following clinical assessments will test attention span? a. Spell WORLD backward. b. Draw a clock. c. Say the days of the week. d. Do arithmetic calculations. e. Explain “a stitch in time saves nine.” ANS: A, C, D

Clinical assessments to test attention span include spell WORLD backward, say the days of the week, and do arithmetic calculations. Drawing a clock tests writing ability, and explaining a “stitch in time saves nine” tests abstract reasoning. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Which of the following are signs and symptoms of dementia? a. Aphasia b. Apathy c. Odd behaviors d. Disintegration of personality e. Lack of awareness of others ANS: A, B, D

Aphasia, apathy, and disintegration of personality are all characteristics of dementia. Odd behaviors and lack of awareness of others are characteristics of autism. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 78 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 06: Growth and Measurement Test Bank—Nursing MULTIPLE CHOICE 1. The gonads begin to secrete estrogen and testosterone during: a. infancy. b. puberty. c. pregnancy. d. early adulthood. ANS: B

At puberty, the gonads secrete testosterone and estrogen. As a result, secondary sex characteristics (e.g., genitalia growth) begin to appear. Maturation occurs at a mean age of 11.5 years in females and 13.5 years in males. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 79 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Developmental changes of puberty are caused mainly by the interaction of the pituitary gland,

gonads, and: a. hypothalamus. b. islet cells. c. thalamus. d. thymus. ANS: A

Under the influence of the hypothalamus, pituitary gland, and gonads, developmental changes of puberty are established. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 79 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. After 50 years of age, stature: a. becomes fixed. b. begins a barely perceptible secondary increase. c. increases at a rate of 0.5 cm/ year. d. declines. ANS: D

As the individual reaches 50 years of age, the intervertebral disk begins to thin and become more compressed, which leads to a decline in stature. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 82 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. By 10 to 12 years of age, lymphatic tissues are about: a. 25% of adult size. b. 50% of adult size. c. the same as adult size. d. twice the size of those in the adult.

ANS: D

Lymphatic tissues are small compared with total body size, but they are almost fully developed at birth. They grow fast and are about twice the adult size by age 10 to 12 years. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 80 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Mrs. Jones has brought her 24-month-old child for a well visit. Which organ(s) completes

physical development more quickly than any other body part? a. Brain b. Kidneys c. Heart d. Lungs ANS: A

Along with the skull, eyes, and ears, the brain completes development more quickly than any other part of the body; its most rapid growth occurs from conception to age 2 years. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 80 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. During adolescence, the head size normally increases as a result of: a. sinus development. b. brain mass increase. c. evolution of lymphatic tissue. d. hypertrophy of myelin. ANS: A

As the facial sinuses grow, the head size enlarges its surface area to accommodate their growth. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 81 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. Fifty percent of an individual’s ideal weight is gained during: a. pregnancy. b. preschool years. c. adolescence. d. early adulthood. ANS: C

During adolescence, the trunk and legs grow the most, causing the organs and the skeletal mass to double in size. In pregnancy, weight gain is accounted for by the growing fetus and pregnancy organs (placenta and uterus). In preschool years, weight is gained at a steady rate, with fat tissue increasing slowly until about 7 years of age. In preschool years, weight is gained at a steady rate, with fat tissue increasing slowly until about 7 years of age. In early adulthood, there is a reduction in size and weight. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 81 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. Gender-specific skeletal differences first occur during: a. the second stage of fetal development. b. late infancy. c. early childhood. d. adolescence. ANS: D

During adolescence, females develop a wider pelvis and males develop broad shoulders; males transition from a slight increase in body fat to more lean muscle mass in later puberty, whereas females maintain an increase in adipose tissue throughout adolescence. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 80 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Mrs. Layton is a 33-year-old patient who is obese. Most adult obesity begins: a. in adolescence. b. in childhood. c. after the skeletal growth is completed. d. once sexual maturation is complete. ANS: A

Seventy percent of adult obesity begins in adolescence, before skeletal growth or sexual maturation is complete. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 80 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. The legs are the fastest growing body part during: a. early infancy. b. late infancy. c. childhood. d. early adulthood. ANS: C

Legs grow the fastest during childhood, whereas the trunk grows fastest in infancy and the skeletal muscles and organs grow fastest in early adulthood. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 81 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Skeletal mass and organ systems double in size during: a. infancy. b. early childhood. c. adolescence. d. early adulthood. ANS: C

During puberty, sex steroids stimulate secretion of growth hormone, causing the organs and skeletal mass to double in size. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 80 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. Optimal infant birth weight is difficult for pregnant adolescents to obtain because: a. they have not completed their own growth spurt. b. there are insufficient uterine supporting structures. c. the amniotic fluid is variable in pregnant adolescents. d. blood volume has not reached adult proportions. ANS: A

Pregnant adolescents younger than 16 years, or less than 2 years from menarche, may still be in their growth spurt. They may require higher weight gains during pregnancy to achieve an optimal infant birth weight. There are sufficient uterine supporting structures in the pregnant adolescent. The amnionic fluid is not variable in pregnant adolescents. Blood volume has reached adult proportions in the pregnant adolescent. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 90 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. How much of the weight gained during a normal pregnancy is accounted for by the fetus? a. Less than 5 pounds b. 6 to 8 pounds c. 9 to 12 pounds d. 13 to 30 pounds ANS: B

The growing fetus accounts for only 6 to 8 pounds of the total weight gained. The remainder results from an increase in maternal tissues (e.g., placenta, amniotic fluid, uterus, blood and fluid volume, breasts, and fat reserves). DIF: Cognitive Level: Remembering (Knowledge) REF: p. 80 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. The rate of weight gain during pregnancy is expected to be: a. greatest in the first trimester. b. greatest in the second trimester. c. greatest in the third trimester. d. about the same in each trimester. ANS: B

The rate of weight gain is slow during the first trimester, rapid during the second trimester, and less rapid during the third trimester. Maternal tissue growth accounts for most of the weight gained in the first and second trimesters, whereas fetal growth accounts for weight gained during the third trimester. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 80 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. During a preventive health care visit, Ms. G, an older patient, states that she is getting shorter.

She says that her son mentioned that her change in stature became noticeable to him during his last visit with her. Her posture appears straight and aligned. When addressing Ms. G.’s present concerns, it is most important to inquire about: a. the number of pregnancies. b. her parents’ heights.

c. a history of scoliosis. d. her usual height and weight. ANS: D

Stature declines after 50 years of age because of progressive thinning of the intervertebral disks, so it is important to determine the patient’s height and weight at this age as a baseline for future trending. DIF: Cognitive Level: Applying (Application) REF: p. 82 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. Over the past 2 decades, there has been a trend toward: a. increased osteoporosis. b. preservation of height. c. obesity in older adults. d. preservation of muscle mass. ANS: C

An increase in overweight and obese older adults has been documented over the past 15 to 20 years. A decrease in weight for height and body mass index has been found with increasing age in patients between 70 and 89 years of age. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 82 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. Milestone achievements are data most likely to appear in the history of: a. adolescents. b. infants. c. school-age children. d. young adults. ANS: B

As part of developmental assessment in infants, milestone achievements at certain ages, such as crawling, laughing, picking up their head, and turning over, are recorded. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 82 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. To estimate an individual’s frame size, the examiner should measure: a. skull circumference. b. the length from the olecranon process to the acromion process. c. elbow breadth. d. hip circumference. ANS: C

With the patient’s right arm extended and the elbow flexed to 90 degrees, measure the elbow breadth using a measuring device or skinfold calipers, held on the same plane as the upper arm, on the two most prominent bones of the elbow. DIF: Cognitive Level: Applying (Application) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

19. Which cultural group tends to have a wide variation in birth weights? a. Native Americans b. Filipinos c. Norwegians d. Puerto Ricans ANS: A

As much as a 362-g difference in mean birth weight exists among several Native American tribes. African American, Asian, Filipino, Hawaiian, and Puerto Rican infants generally weigh less than white infants. Filipinos, Norwegians, and Puerto Ricans do not have a wide variation in birth weights. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. Healthy term babies generally double their birth weight by what age? a. 3 months b. 5 months c. 9 months d. 12 months ANS: B

In general, healthy infants double their birth weight by 4 to 5 months of age and triple their birth weight by 12 months of age. Formula-fed infants are heavier after the first 6 months of life than breast-fed infants; they grow faster in the first 6 months of life and experience slower growth in the second 6 months of the first year. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 84 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. Infants born to the same parents are normally within which range of weight of each other? a. 6 ounces b. 12 ounces c. 1 pound d. 2 pounds ANS: A

Siblings born at term to the same parents usually weigh within 6 ounces of each other. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 83 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. A marker for nutritional status is the: a. head circumference. b. waist-to-hip ratio. c. standing height. d. triceps skinfold thickness. ANS: D

The measurement of skinfold or fatfold thickness provides another parameter to evaluate the nutritional status of the patient. The jaws of skinfold thickness calipers must be correctly placed to obtain an accurate reading.

DIF: Cognitive Level: Applying (Application) REF: p. 83 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. To measure head circumference, the tape is wrapped snugly around the child’s head at the

occipital protuberance and the: a. supraorbital prominence. b. brow line. c. nasal bridge. d. chin. ANS: A

The measuring tape should be snugly wrapped around the child’s head at the occipital protuberance and supraorbital prominence, thereby documenting the largest circumference. Care should be taken to ensure that the tape does not cut the skin. Make the reading to the nearest 0.5 cm or inch, and remember to remeasure the head circumference at least once to check the accuracy of your measurement. DIF: Cognitive Level: Applying (Application) REF: p. 84 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. Between 5 and 24 months of life, the infant’s chest circumference is normally: a. about equal to the head circumference. b. greater than head circumference by 2 inches. c. smaller than head circumference by about 4 inches. d. at least 2 inches smaller than head circumference. ANS: A

Between the ages of 5 months and 2 years, the infant’s chest circumference should closely approximate the head circumference; the ratio should be monitored so that possible microcephaly can be identified. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 85 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. In clinical practice, the Ballard Assessment Tool is used to assess a newborn’s: a. length. b. weight. c. lung maturity. d. gestational age. ANS: D

The Ballard Assessment Tool assesses six physical and six neuromuscular characteristics and is administered within 36 hours of birth to confirm the newborn’s gestational age. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 85 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. Which of the following situations poses the most concern? a. The child whose weight and height ratios have remained at the 50th percentile b. The child whose weight and height ratios have stayed between the 90th and 95th

percentiles c. The child whose weight and height ratios have never been above the 50th percentile d. The child whose weight and height ratios have dropped 15 percentiles since the last visit ANS: D

Over time, interval measurements should demonstrate that the child has established a growth pattern, indicated by consistently following a percentile curve on the growth chart. Greatest concern is for the child who is trending down in a more dramatic fashion. Children who suddenly fall below or rise above their established percentile growth curve should be examined more closely to determine the cause. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 82 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. The upper-to-lower segment ratio should be calculated: a. bimonthly for the first year of life. b. annually for the first 5 years. c. only when a child is suspected of having a growth problem or unusual body

proportions. d. in children of first-generation immigrants. ANS: C

The upper-to-lower segment ratio is calculated when a child is suspected of having a growth problem or unusual body proportions. DIF: Cognitive Level: Applying (Application) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. A Mexican American mother brings her 12-year-old daughter to the clinic because this child is

not maturing as quickly as her classmates. You examine the daughter and determine that her growth and physical findings are within normal limits. You should explain to the family that: a. Mexican Americans may develop more slowly than other ethnic groups. b. more tests should be conducted because the family appears so worried. c. the daughter should drink more juices and eat more fruit. d. there is a serious problem with the daughter’s development. ANS: A

Mexican Americans typically are taller than Asian children but shorter than Native American, white, and African American children. This child’s growth pattern should be similar to other children of similar ethnicity. More tests are not required. The daughter does not need to drink more juices and eat more fruit. There is no problem with the daughter’s development. DIF: Cognitive Level: Applying (Application) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 29. Which of following statements regarding female pubertal changes is true? a. Most adolescent girls will develop breasts before they develop pubic hair. b. Peak height velocity should occur after menarche. c. Breast asymmetry is an abnormal finding. d. Menarche should occur by Tanner breast stage 2.

ANS: A

In two thirds of the population of girls, breasts begin to develop before pubic hair. Peak height velocity actually occurs about 1 year before menarche, breast asymmetry is common, and menarche occurs after Tanner breast stage 2. Peak height velocity will not occur after menarche. Breast asymmetry is not an abnormal finding. Menarche does not generally occur by Tanner breast stage 2. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 30. At what age does peak height growth velocity occur in boys? a. 10 years b. 12 years c.

years

d.

years

ANS: C

Peak height velocity occurs at an average age of

years in boys.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 31. What is the youngest age at which pubic hair growth in the male may be considered normal? a. 7 years b. 8 years c. 9 years d. 10 years ANS: C

In males, sexual development before 9 years of age is precocious puberty and is considered an abnormal finding; sexual development after 9 years of age is considered normal puberty. DIF: Cognitive Level: Applying (Application) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 32. Which Tanner stage is marked by the most significant growth in penis length? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: C

Tanner stage 3 is marked by enlargement of the penis, especially in length. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 90 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 33. Which Tanner stage corresponds to a secondary areola mound development above the breast? a. Stage 2 b. Stage 3

c. Stage 4 d. Stage 5 ANS: C

Tanner stage 4 depicts the stage at which the areola forms a second mound above the breast. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 88 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 34. A pregnant woman of normal prepregnancy weight should be expected to gain how much

weight per week during the second and third trimesters of pregnancy? a. 1 pound b.

pounds c. 2 pounds d.

pounds

ANS: A

Expected weight gain in the first trimester is variable, between 1 and 2 kg (2 to 4 pounds); however, in the second and third trimesters, weekly weight gain should be approximately 0.45 kg (1 pound) per week. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 89 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 35. A prominent forehead, large nose, large jaw, and elongation of the facial bones and extremities

are signs of: a. infantile hydrocephalus. b. acromegaly. c. Cushing syndrome. d. achondroplasia. ANS: B

A prominent forehead, large nose, large jaw, and elongation of the facial bones and extremities are all prominent characteristics of acromegaly; a prominent forehead can also occur with achondroplasia, but hypoplasia of the midface differentiates the two. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 92 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 36. Round face, preauricular fat, hyperpigmentation, and “buffalo hump” in the posterior cervical

area are associated with: a. infantile hydrocephalus. b. acromegaly. c. Cushing syndrome. d. achondroplasia. ANS: C

Round face, preauricular fat, hyperpigmentation, and a buffalo hump in the posterior cervical area are all commonly associated with Cushing syndrome; the buffalo hump distinguishes Cushing syndrome from the other choices.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 92 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation COMPLETION 1. A woman with a normal prepregnancy body mass index (BMI) should gain approximately

_____ pounds during pregnancy. ANS:

30 Women of normal BMI should expect to gain between 25 and 35 pounds during pregnancy. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 89 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. An 11-year-old boy is brought in for an annual physical examination by his mother. You

suspect _______________ when you measure his arm span at 65 inches and his height at 60 inches. ANS:

Marfan syndrome Arm span that is greater than a child’s height is associated with Marfan syndrome. Children with Marfan syndrome can have cardiovascular problems and should be thoroughly evaluated. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 87 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Infants normally increase their birth length by ____% during the first year of life. ANS:

50 Infant length generally increases by 50% in the first year of life. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 84 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The term large for gestational age (LGA) indicates that an infant is larger than ____% of

infants born at the same number of weeks’ gestation. ANS:

90 LGA corresponds to an infant whose weight is classified as greater than the 90th percentile. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 86 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE 1. Which of the following are signs and symptoms of hydrocephalus? (Select all that apply.) a. Early closed suture lines b. Hyperreflexia c. Irritable, poor feeding d. Does not meet expected height and weight e. Difficulty holding head up f. Rapidly increasing head circumference ANS: B, C, E, F

Signs and symptoms of hydrocephalus include enlarged head, difficulty holding head up, irritable, lack of energy, and poor feeding. Rapidly increasing head circumference, tense, full, or bulging fontanel, increased tone, or hyperreflexia do not indicate hydrocephalus. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 93 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 07: Nutrition Test Bank—Nursing MULTIPLE CHOICE 1. Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her

current weight. In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient? a. Iron b. Thiamine c. Calcium d. Fat ANS: D

Carbohydrates, protein, and fat are referred to as macronutrients because they are required in large amounts. Iron, thiamine, and calcium are minerals. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 95 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Macronutrients are so named because they: a. have high molecular weights. b. form long chemical chains. c. tend to increase waist measurements. d. are required in large amounts. ANS: D

Carbohydrates, protein, and fat are referred to as macronutrients because they are required in large amounts. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 95 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The body handles excess carbohydrate ingestion by: a. storing it as fat. b. raising the metabolic rate. c. excreting it in urine and stool. d. enzyme degradation. ANS: A

Excess carbohydrates, not used for fueling the body’s demands, are stored in fatty tissues. The body does not handle excess carbohydrate ingestion by raising the metabolic rate or by enzyme degradation. Excess carbohydrate is not excreted; it is stored. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 96 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. A college student comes to the student health center complaining of difficulty in concentrating

during class and while studying. The diet that would contribute to this problem is one that contains mostly: a. fruit and vegetables.