Advanced Health Assessment and Diagnostic Reasoning, 3rd Edition Test Bank

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Advanced Health Assessment and DiagnosticReasoning 3rdEdition RhoadsTESTBANK/STUDY SOURCEChapter 1:Interview and History Taking StrategiesMULTIPLECHOICE1.Thenurseisconductinganinterviewwithawomanwhohasrecentlylearnedthatsheispregnantandwhohascometotheclinictodaytobeginprenatalcare.Thewomanstatesthatsheandherhusbandareexcitedaboutthepregnancybuthaveafewquestions.Shelooksnervouslyatherhandsduringtheinterviewandsighsloudly.Consideringtheconceptofcommunication,whichstatementdoesthenurseknowtobemostaccurate?Thewomanis:a.Excitedaboutherpregnancybutnervousaboutthelabor.b.Exhibitingverbalandnonverbalbehaviorsthatdonotmatch.c.Excitedaboutherpregnancy,butherhusbandisnotandthisisupsettingtoher.d.Notexcitedaboutherpregnancybutbelievesthenursewillnegativelyrespondtoherifshestatesthis.ANS:BCommunicationisallbehaviors,consciousandunconscious,verbalandnonverbal.Allbehaviorshavemeaning.Herbehaviordoesnotimplythatsheisnervousaboutlabor,upsetbyherhusband,orworriedaboutthenursesresponse.2.Receivingisapartofthecommunicationprocess.Whichreceiverismostlikelytomisinterpretamessagesentbyahealthcareprofessional?a.Well-adjustedadolescentwhocameinforasportsphysicalb.Recoveringalcoholicwhocameinforabasicphysicalexaminationc.Manwhosewifehasjustbeendiagnosedwithlungcancerd.ManwithahearingimpairmentwhousessignlanguagetocommunicateandwhohasaninterpreterwithhimANS:CThereceiverattachesmeaningdeterminedbyhisorherexperiences,culture,self-concept,andcurrentphysicalandemotionalstates.Themanwhosewifehasjustbeendiagnosedwithlungcancermaybeexperiencingemotionsthataffecthisreceiving.3.Thenursemakeswhichadjustmentinthephysicalenvironmenttopromotethesuccessofaninterview?a.Reducesnoisebyturningofftelevisionsandradiosb.Reducesthedistancebetweentheinterviewerandthepatientto2feetorlessc.Providesadimlightthatmakestheroomcozyandhelpsthepatientrelaxd.Arrangesseatingacrossadeskortabletoallowthepatientsomepersonalspace

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ANS:AThenurseshouldreducenoisebyturningoffthetelevision,radio,andotherunnecessaryequipment,becausemultiplestimuliareconfusing.Theinterviewerandpatientshouldbeapproximately4to5feetapart;theroomshouldbewell-lit,enablingtheinterviewerandpatienttoseeeachotherclearly.Havingatableordeskinbetweenthetwopeoplecreatestheideaofabarrier;equal-statusseating,ateyelevel,isbetter.4.Inaninterview,thenursemayfinditnecessarytotakenotestoaidhisorhermemorylater.Whichstatementistrueregardingnote-taking?a.Note-takingmayimpedethenursesobservationofthepatientsnonverbalbehaviors.b.Note-takingallowsthepatienttocontinueathisorherownpaceasthenurserecordswhatissaid.c.Note-takingallowsthenursetoshiftattentionawayfromthepatient,resultinginanincreasedcomfortlevel.d.Note-takingallowsthenursetobreakeyecontactwiththepatient,whichmayincreasehisorherlevelofcomfort.ANS:ATheuseofhistoryformsandnote-takingmaybeunavoidable.However,thenursemustbeawarethatnote-takingduringtheinterviewhasdisadvantages.Itbreakseyecontacttoooftenandshiftstheattentionawayfromthepatient,whichdiminisheshisorhersenseofimportance.Note-takingmayalsointerruptthepatientsnarrativeflow,anditimpedestheobservationofthepatientsnonverbalbehavior.5.Thenurseasks,Iwouldliketoaskyousomequestionsaboutyourhealthandyourusualdailyactivitiessothatwecanbetterplanyourstayhere.Thisquestionisfoundatthe__________phaseoftheinterviewprocess.a.Summaryb.Closingc.Bodyd.OpeningorintroductionANS:DWhengatheringacompletehistory,thenurseshouldgivethereasonfortheinterviewduringtheopeningorintroductionphaseoftheinterview,notduringorattheendoftheinterview.6.Awomanhasjustenteredtheemergencydepartmentafterbeingbatteredbyherhusband.Thenurseneedstogetsomeinformationfromhertobegintreatment.Whatisthebestchoiceforanopeningphaseoftheinterviewwiththispatient?a.Hello,Nancy,mynameisMrs.C.b.Hello,Mrs.H.,mynameisMrs.C.Itsureiscoldtoday!c.Mrs.H.,mynameisMrs.C.Howareyou?d.Mrs.H.,mynameisMrs.C.Illneedtoaskyouafewquestionsaboutwhathappened.ANS:DAddressthepersonbyusinghisorhersurname.Thenurseshouldintroducehimorherselfandgivethereasonfortheinterview.Friendlysmalltalkisnotneededtobuildrapport.

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7.Duringaninterview,thenursestates,Youmentionedhavingshortnessofbreath.Tellmemoreaboutthat.Whichverbalskillisusedwiththisstatement?a.Reflectionb.Facilitationc.Directquestiond.Open-endedquestionANS:DTheopen-endedquestionasksfornarrativeinformation.Itstatesthetopictobediscussedbutonlyingeneralterms.Thenurseshoulduseittobegintheinterview,tointroduceanewsectionofquestions,andwheneverthepersonintroducesanewtopic.8.Apatienthasfinishedgivingthenurseinformationaboutthereasonheisseekingcare.Whenreviewingthedata,thenursefindsthatsomeinformationaboutpasthospitalizationsismissing.Atthispoint,whichstatementbythenursewouldbemostappropriatetogatherthesedata?a.Mr.Y.,atyourage,surelyyouhavebeenhospitalizedbefore!b.Mr.Y.,IjustneedpermissiontogetyourmedicalrecordsfromCountyMedical.c.Mr.Y.,youmentionedthatyouhavebeenhospitalizedonseveraloccasions.Wouldyoutellmemoreaboutthat?d.Mr.Y.,Ijustneedtogetsomeadditionalinformationaboutyourpasthospitalizations.Whenwasthelasttimeyouwereadmittedforchestpain?ANS:DThenurseshouldusedirectquestionsafterthepersonsopeningnarrativetofillinanydetailsheorsheleftout.Thenursealsoshouldusedirectquestionswhenspecificfactsareneeded,suchaswhenaskingaboutpasthealthproblemsorduringthereviewofsystems.9.Inusingverbalresponsestoassistthepatientsnarrative,someresponsesfocusonthepatientsframeofreferenceandsomefocusonthehealthcareprovidersperspective.Anexampleofaverbalresponsethatfocusesonthehealthcareprovidersperspectivewouldbe:a.Empathy.b.Reflection.c.Facilitation.d.Confrontation.ANS:DWhenthehealthcareproviderusestheresponseofconfrontation,theframeofreferenceshiftsfromthepatientsperspectivetotheperspectiveofthehealthcareprovider,andthehealthcareproviderstartstoexpresshisorherownthoughtsandfeelings.Empathy,reflection,andfacilitationresponsesfocusonthepatientsframeofreference.10.Whentakingahistoryfromanewlyadmittedpatient,thenursenoticesthatheoftenpausesandexpectantlylooksatthenurse.Whatwouldbethenursesbestresponsetothisbehavior?a.Besilent,andallowhimtocontinuewhenheisready.b.Smileathimandsay,Dontworryaboutallofthis.Imsurewecanfindoutwhyyourehavingthesepains.

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c.Leanbackinthechairandask,Youarelookingatmekindoffunny;thereisntanythingwrong,isthered.Standupandsay,Icanseethatthisinterviewisuncomfortableforyou.Wecancontinueitanothertime.ANS:ASilentattentivenesscommunicatesthatthepersonhastimetothinkandtoorganizewhatheorshewishestosaywithoutaninterruptionfromthenurse.Healthprofessionalsmostofteninterruptthisthinkingsilence.Theotherresponsesarenotconducivetoidealcommunication.11.Awomanisdiscussingtheproblemssheishavingwithher2-year-oldson.Shesays,Hewontgotosleepatnight,andduringthedayhehasseveralfits.Igetsoupsetwhenthathappens.Thenursesbestverbalresponsewouldbe:a.Goon,Imlistening.b.Fits?Tellmewhatyoumeanbythis.c.Yes,itcanbeupsettingwhenachildhasafit.d.Dontbeupsetwhenhehasafit;every2yearoldhasfits.ANS:BThenurseshoulduseclarificationwhenthepersonswordchoiceisambiguousorconfusing(e.g.,Tellmewhatyoumeanbyfits.).Clarificationisalsousedtosummarizethepersonswordsortosimplifythewordstomakethemclearer;thenurseshouldthenaskifheorsheisontherighttrack.12.A17-year-oldsinglemotherisdescribinghowdifficultitistoraisea3-year-oldchildbyherself.Duringthecourseoftheinterviewshestates,Icantbelievemyboyfriendleftmetodothisbymyself!Whataterriblethingtodotome!Whichoftheseresponsesbythenurseusesempathy?a.Youfeelalone.b.Youcantbelieveheleftyoualone?c.Itmustbesohardtofacethisallalone.d.Iwouldbeangry,too;raisingachildaloneisnopicnic.ANS:CAnempatheticresponserecognizesthefeelingandputsitintowords.Itnamesthefeeling,allowsitsexpression,andstrengthensrapport.Otherempatheticresponsesare,Thismustbeveryhardforyou,Iunderstand,orsimplyplacingyourhandonthepersonsarm.Simplyreflectingthepersonswordsoragreeingwiththepersonisnotanempatheticresponse.13.Amanhasbeenadmittedtotheobservationunitforobservationafterbeingtreatedforalargecutonhisforehead.Asthenurseworksthroughtheinterview,oneofthestandardquestionshastodowithalcohol,tobacco,anddruguse.Whenthenurseaskshimabouttobaccouse,hestates,Iquitsmokingaftermywifedied7yearsago.However,thenursenoticesanopenpackofcigarettesinhisshirtpocket.Usingconfrontation,thenursecouldsay:a.Mr.K.,Iknowthatyouarelying.b.Mr.K.,comeon,tellmehowmuchyousmoke.c.Mr.K.,Ididntrealizeyourwifehaddied.Itmustbedifficultforyouatthistime.

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Pleasetellmemoreaboutthat.d.Mr.K.,youhavesaidthatyoudontsmoke,butIseethatyouhaveanopenpackofcigarettesinyourpocket.ANS:DInthecaseofconfrontation,acertainaction,feeling,orstatementhasbeenobserved,andthenursenowfocusesthepatientsattentiononit.Thenurseshouldgivehonestfeedbackaboutwhatisseenorfelt.Confrontationmayfocusonadiscrepancy,orthenursemayconfrontthepatientwhenpartsofthestoryareinconsistent.Theotherstatementsarenotappropriate.14.Thenursehasusedinterpretationregardingapatientsstatementoractions.Afterusingthistechnique,itwouldbebestforthenurseto:a.Apologize,becauseusinginterpretationcanbedemeaningforthepatient.b.Allowtimeforthepatienttoconfirmorcorrecttheinference.c.Continuewiththeinterviewasthoughnothinghashappened.d.Immediatelyrestatethenursesconclusiononthebasisofthepatientsnonverbalresponse.ANS:BInterpretationisnotbasedondirectobservationasisconfrontation,butitisbasedononesinferenceorconclusion.Thenurserisksmakingthewronginference.Ifthisisthecase,thenthepatientwillcorrectit.However,eveniftheinferenceiscorrect,interpretationhelpspromptfurtherdiscussionofthetopic.15.Duringaninterview,awomansays,IhavedecidedthatIcannolongerallowmychildrentolivewiththeirfathersviolence,butIjustcantseemtoleavehim.Usinginterpretation,thenursesbestresponsewouldbe:a.Youaregoingtoleavehim?b.Ifyouareafraidforyourchildren,thenwhycantyouleave?c.Itsoundsasifyoumightbeafraidofhowyourhusbandwillrespond.d.Itsoundsasthoughyouhavemadeyourdecision.Ithinkitisagoodone.ANS:CThisstatementisnotbasedononesinferenceorconclusion.Itlinksevents,makesassociations,orimpliescause.Interpretationalsoascribesfeelingsandhelpsthepersonunderstandhisorherownfeelingsinrelationtotheverbalmessage.Theotherstatementsdonotreflectinterpretation.16.Apregnantwomanstates,IjustknowlaborwillbesopainfulthatIwontbeabletostandit.Iknowitsoundsawful,butIreallydreadgoingintolabor.Thenurserespondsbystating,Oh,dontworryaboutlaborsomuch.Ihavebeenthroughit,andalthoughitispainful,manygoodmedicationsareavailabletodecreasethepain.Whichstatementistrueregardingthisresponse?Thenursesreplywasa:a.Therapeuticresponse.Bysharingsomethingpersonal,thenursegiveshopetothiswoman.b.Nontherapeuticresponse.Byprovidingfalsereassurance,thenurseactuallycutofffurtherdiscussionothewomansfears.c.Therapeuticresponse.Byprovidinginformationaboutthemedicationsavailable,thenurseisgivinginformationtothewoman.d.Nontherapeuticresponse.Thenurseisessentiallygivingthemessagetothewoman

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thatlaborcannotbetoleratedwithoutmedication.ANS:BByprovidingfalseassuranceorreassurance,thiscouragebuilderrelievesthewomansanxietyandgivesthenursethefalsesenseofhavingprovidedcomfort.However,forthewoman,providingfalseassuranceorreassuranceactuallyclosesoffcommunication,trivializesheranxiety,andeffectivelydeniesanyfurthertalkofit.17.Duringavisittotheclinic,apatientstates,ThedoctorjusttoldmehethoughtIoughttostopsmoking.HedoesntunderstandhowhardIvetried.Ijustdontknowthebestwaytodoit.WhatshouldIdo?Thenursesmostappropriateresponseinthiscasewouldbe:a.IdquitifIwereyou.Thedoctorreallyknowswhatheistalkingabout.b.Wouldyoulikesomeinformationaboutthedifferentwaysapersoncanquitsmoking?c.Stoppingyourdependenceoncigarettescanbeverydifficult.Iunderstandhowyoufeel.d.Whyareyouconfused?Didntthedoctorgiveyoutheinformationaboutthesmokingcessationprogramweoffer?ANS:BClarificationshouldbeusedwhenthepersonswordchoiceisambiguousorconfusing.Clarificationisalsousedtosummarizethepersonswordsortosimplifythewordstomakethemclearer;thenurseshouldthenaskifheorsheisontherighttrack.Theotherresponsesgiveunwantedadviceordonotofferahelpfulresponse.18.Asthenurseentersapatientsroom,thenursefindshercrying.Thepatientstatesthatshehasjustfoundoutthatthelumpinherbreastiscancerandsays,Imsoafraidof,um,youknow.Thenursesmosttherapeuticresponsewouldbetosayinagentlemanner:a.Youreafraidyoumightloseyourbreast?b.No,Imnotsurewhatyouaretalkingabout.c.Illwaithereuntilyougetyourselfundercontrol,andthenwecantalk.d.Icanseethatyouareveryupset.Perhapsweshoulddiscussthislater.ANS:AReflectionechoesthepatientswords,repeatingpartofwhatthepersonhasjustsaid.Reflectioncanalsohelpexpressthefeelingsbehindapersonswords.19.Anurseistakingcompletehealthhistoriesonallofthepatientsattendingawellnessworkshop.Onthehistoryform,oneofthewrittenquestionsasks,Youdontsmoke,drink,ortakedrugs,doyou?Thisquestionisanexampleof:a.Talkingtoomuch.b.Usingconfrontation.c.Usingbiasedorleadingquestions.d.Usingbluntlanguagetodealwithdistastefultopics.ANS:CThisquestionisanexampleofusingleadingorbiasedquestions.Asking,Youdontsmoke,doyou?impliesthatoneanswerisbetterthananother.Ifthepersonwantstopleasesomeone,thenheorsheiseitherforcedtoanswerinawaythatcorrespondstohisorherimpliedvaluesorismadetofeelguiltywhenadmittingtheotheranswer.

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20.Whenobservingapatientsverbalandnonverbalcommunication,thenursenoticesadiscrepancy.Whichstatementistrueregardingthissituation?Thenurseshould:a.Asksomeonewhoknowsthepatientwelltohelpinterpretthisdiscrepancy.b.Focusonthepatientsverbalmessage,andtrytoignorethenonverbalbehaviors.c.Trytointegratetheverbalandnonverbalmessagesandtheninterpretthemasanaverage.d.Focusonthepatientsnonverbalbehaviors,becausetheseareoftenmorereflectiveofapatientstruefeelings.ANS:DWhennonverbalandverbalmessagesarecongruent,theverbalmessageisreinforced.Whentheyareincongruent,thenonverbalmessagetendstobethetrueonebecauseitisunderlessconsciouscontrol.Thusstudyingthenonverbalmessagesofthepatientsandexaminersandunderstandingtheirmeaningsareimportant.Theotherstatementsarenottrue.21.Duringaninterview,aparentofahospitalizedchildissittinginanopenposition.Astheinterviewerbeginstodiscusshissonstreatment,however,hesuddenlycrosseshisarmsagainsthischestandcrosseshislegs.Thischangedposturewouldsuggestthattheparentis:a.Simplychangingpositions.b.Morecomfortableinthisposition.c.Tiredandneedsabreakfromtheinterview.d.Uncomfortabletalkingabouthissonstreatment.ANS:DThepersonspositionisnoted.Anopenpositionwiththeextensionoflargemusclegroupsshowsrelaxation,physicalcomfort,andawillingnesstoshareinformation.Aclosedpositionwiththearmsandlegscrossedtendstolookdefensiveandanxious.Anychangeinpostureshouldbenoted.Ifapersoninarelaxedpositionsuddenlytenses,thenthischangeinposturesuggestspossiblediscomfortwiththenewtopic.22.Amotherbringsher28-month-olddaughterintotheclinicforawell-childvisit.Atthebeginningofthevisit,thenursefocusesattentionawayfromthetoddler,butastheinterviewprogresses,thetoddlerbeginstowarmupandissmilingshylyatthenurse.Thenursewillbemostsuccessfulininteractingwiththetoddlerifwhichisdonenext?a.Ticklethetoddler,andgethertolaugh.b.Stoopdowntoherlevel,andaskheraboutthetoysheisholding.c.Continuetoignoreheruntilitistimeforthephysicalexamination.d.Askthemothertoleaveduringtheexaminationofthetoddler,becausetoddlersoftenfusslessiftheirparentisnotinview.ANS:BAlthoughmostofthecommunicationiswiththeparent,thenurseshouldnotcompletelyignorethechild.Makingcontactwillhelpeasethetoddlerlaterduringthephysicalexamination.Thenurseshouldbeginbyaskingaboutthetoysthechildisplayingwithoraboutaspecialdollorteddybearbroughtfromhome.Doesyourdollhaveaname?orWhatcanyourtruckdo?Stoopdowntomeetthechildathisorhereyelevel.23.Duringanexaminationofa3-year-oldchild,thenursewillneedtotakeherbloodpressure.Whatmightthenursedototrytogainthechildsfullcooperation?

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a.Tellthechildthatthebloodpressurecuffisgoingtogiveherarmabighug.b.Tellthechildthatthebloodpressurecuffisasleepandcannotwakeup.c.Givethebloodpressurecuffanameandrefertoitbythisnameduringtheassessment.d.Tellthechildthatbyusingthebloodpressurecuff,wecanseehowstronghermusclesare.ANS:DTakethetimetogiveashort,simpleexplanationwithaconcreteexplanationforanyunfamiliarequipmentthatwillbeusedonthechild.Preschoolersareanimistic;theyimagineinanimateobjectscancomealiveandhavehumancharacteristics.Thusabloodpressurecuffcanwakeupandbiteorpinch.24.A16-year-oldboyhasjustbeenadmittedtotheunitforovernightobservationafterbeinginanautomobileaccident.Whatisthenursesbestapproachtocommunicatingwithhim?a.Useperiodsofsilencetocommunicaterespectforhim.b.Betotallyhonestwithhim,eveniftheinformationisunpleasant.c.Tellhimthateverythingthatisdiscussedwillbekepttotallyconfidential.d.Useslanglanguagewhenpossibletohelphimopenup.ANS:BSuccessfulcommunicationwithanadolescentispossibleandcanberewarding.Theguidelinesaresimple.Thefirstconsiderationisonesattitude,whichmustbeoneofrespect.Second,communicationmustbetotallyhonest.Anadolescentsintuitionishighlytunedandcandetectphoninessorthewithholdingofinformation.Alwaystellhimorherthetruth.25.A75-year-oldwomanisattheofficeforapreoperativeinterview.Thenurseisawarethattheinterviewmaytakelongerthaninterviewswithyoungerpersons.Whatisthereasonforthis?a.Anagedpersonhasalongerstorytotell.b.Anagedpersonisusuallylonelyandlikestohavesomeonewithwhomtotalk.c.Agedpersonslosemuchoftheirmentalabilitiesandrequirelongertimetocompleteaninterview.d.Asapersonages,heorsheisunabletohear;thustheinterviewerusuallyneedstorepeatmuchofwhatissaid.ANS:ATheinterviewusuallytakeslongerwitholderadultsbecausetheyhavealongerstorytotell.Itisnotnecessarilytruethatallolderadultsarelonely,havelostmentalabilities,orarehardofhearing.26.Thenurseisinterviewingamalepatientwhohasahearingimpairment.Whattechniqueswouldbemostbeneficialincommunicatingwiththispatient?a.Determinethecommunicationmethodheprefers.b.Avoidusingfacialandhandgesturesbecausemosthearing-impairedpeoplefindthisdegrading.c.Requestasignlanguageinterpreterbeforemeetingwithhimtohelpfacilitatethecommunication.d.Speakloudlyandwithexaggeratedfacialmovementwhentalkingwithhimbecausedoingsowillhelphimlipread.ANS:A

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Thenurseshouldaskthedeafpersonthepreferredwaytocommunicatebysigning,lipreading,orwriting.Ifthepersonpreferslipreading,thenthenurseshouldbesuretofacehimsquarelyandhavegoodlightingonthenursesface.Thenurseshouldnotexaggeratelipmovementsbecausethisdistortswords.Similarly,shoutingdistortsthereceptionofahearingaidthepersonmaywear.Thenurseshouldspeakslowlyandsupplementhisorhervoicewithappropriatehandgesturesorpantomime.27.Duringaprenatalcheck,apatientbeginstocryasthenurseasksheraboutpreviouspregnancies.Shestatesthatsheisrememberingherlastpregnancy,whichendedinmiscarriage.Thenursesbestresponsetohercryingwouldbe:a.Imsosorryformakingyoucry!b.Icanseethatyouaresadrememberingthis.Itisallrighttocry.c.WhydontIstepoutforafewminutesuntilyourefeelingbetter?d.Icanseethatyoufeelsadaboutthis;whydontwetalkaboutsomethingelse?ANS:BAbeginningexaminerusuallyfeelshorrifiedwhenthepatientstartscrying.Whenthenursesayssomethingthatmakesthepersoncry,thenurseshouldnotthinkheorshehashurttheperson.Thenursehassimplyhitonanimportanttopic;therefore,movingontoanewtopicisessential.Thenurseshouldallowthepersontocryandtoexpresshisorherfeelingsfully.Thenursecanofferatissueandwaituntilthecryingsubsidestotalk.28.Afemalenurseisinterviewingamanwhohasrecentlyimmigrated.Duringthecourseoftheinterview,heleansforwardandthenfinallymoveshischaircloseenoughthathiskneesarenearlytouchingthenursesknees.Thenursebeginstofeeluncomfortablewithhisproximity.Whichstatementmostcloselyreflectswhatthenurseshoulddonext?a.Thenurseshouldtrytorelax;thesebehaviorsareculturallyappropriateforthisperson.b.Thenurseshoulddiscreetlymovehisorherchairbackuntilthedistanceismorecomfortable,andthencontinuewiththeinterview.c.Thesebehaviorsareindicativeofsexualaggression,andthenurseshouldconfrontthispersonabouthisbehaviors.d.Thenurseshouldlaughbuttellhimthatheorsheisuncomfortablewithhisproximityandaskhimtomoveaway.ANS:ABoththepatientsandthenursessenseofspatialdistancearesignificantthroughouttheinterviewandphysicalexamination,withculturallyappropriatedistancezonesvaryingwidely.Someculturalgroupsvalueclosephysicalproximityandmayperceiveahealthcareproviderwhoisdistancinghimorherselfasbeingaloofandunfriendly.29.AfemaleAmericanIndianhascometotheclinicforfollow-updiabeticteaching.Duringtheinterview,thenursenoticesthatshenevermakeseyecontactandspeaksmostlytothefloor.Whichstatementistrueregardingthissituation?a.Thewomanisnervousandembarrassed.b.Shehassomethingtohideandisashamed.c.Thewomanisshowinginconsistentverbalandnonverbalbehaviors.d.Sheisshowingthatsheiscarefullylisteningtowhatthenurseissaying.

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ANS:DEyecontactisperhapsamongthemostculturallyvariablenonverbalbehaviors.Asian,AmericanIndian,Indochinese,Arabian,andAppalachianpeoplemayconsiderdirecteyecontactimpoliteoraggressive,andtheymayaverttheireyesduringtheinterview.AmericanIndiansoftenstareatthefloorduringtheinterview,whichisaculturallyappropriatebehavior,indicatingthatthelistenerispayingcloseattentiontothespeaker.30.Thenurseisperformingahealthinterviewonapatientwhohasalanguagebarrier,andnointerpreterisavailable.Whichisthebestexampleofanappropriatequestionforthenursetoaskinthissituation?a.Doyoutakemedicine?b.Doyousterilizethebottles?c.Doyouhavenauseaandvomiting?d.Youhavebeentakingyourmedicine,haventyou?ANS:AInasituationduringwhichalanguagebarrierexistsandnointerpreterisavailable,simplewordsshouldbeused,avoidingmedicaljargon.Theuseofcontractionsandpronounsshouldalsobeavoided.Nounsshouldberepeatedlyused,andonetopicatatimeshouldbediscussed.31.Amanarrivesattheclinicforhisannualwellnessphysical.Heisexperiencingnoacutehealthproblems.Whichquestionorstatementbythenurseismostappropriatewhenbeginningtheinterview?a.Howisyourfamily?b.Howisyourjob?c.Tellmeaboutyourhypertension.d.Howhasyourhealthbeensinceyourlastvisit?ANS:DOpen-endedquestionsareusedforgatheringnarrativeinformation.Thistypeofquestioningshouldbeusedtobegintheinterview,tointroduceanewsectionofquestions,andwheneverthepersonintroducesanewtopic.32.Thenursemakesthiscommenttoapatient,Iknowitmaybehard,butyoushoulddowhatthedoctororderedbecausesheistheexpertinthisfield.Whichstatementiscorrectaboutthenursescomment?a.Thiscommentisinappropriatebecauseitshowsthenursesbias.b.Thiscommentisappropriatebecausemembersofthehealthcareteamareexpertsintheirareaofpatientcare.c.Thistypeofcommentpromotesdependencyandinferiorityonthepartofthepatientandisbestavoidedinaninterviewsituation.d.Usingauthoritystatementswhendealingwithpatients,especiallywhentheyareundecidedaboutanissue,isnecessaryattimes.ANS:CUsingauthorityresponsespromotesdependencyandinferiority.Avoidingtheuseofauthorityisbest.Althoughthehealthcareproviderandpatientdonothaveequalprofessionalknowledge,bothhaveequallyworthyrolesinthehealthprocess.Theotherstatementsarenotcorrect.

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33.AfemalepatientdoesnotspeakEnglishwell,andthenurseneedstochooseaninterpreter.Whichofthefollowingwouldbethemostappropriatechoice?a.Trainedinterpreterb.Malefamilymemberc.Femalefamilymemberd.VolunteercollegestudentfromtheforeignlanguagestudiesdepartmentANS:AWheneverpossible,thenurseshoulduseatrainedinterpreter,preferablyonewhoknowsmedicalterminology.Ingeneral,anolder,morematureinterpreterispreferredtoayounger,lessexperiencedone,andthesamegenderispreferredwhenpossible.34.Duringafollow-upvisit,thenursediscoversthatapatienthasnotbeentakinghisinsulinonaregularbasis.Thenurseasks,Whyhaventyoutakenyourinsulin?Whichstatementisanappropriateevaluationofthisquestion?a.Thisquestionmayplacethepatientonthedefensive.b.Thisquestionisaninnocentsearchforinformation.c.Discussinghisbehaviorwithhiswifewouldhavebeenbetter.d.Adirectquestionisthebestwaytodiscoverthereasonsforhisbehavior.ANS:ATheadultsuseofwhyquestionsusuallyimpliesblameandcondemnationandplacesthepersononthedefensive.Theotherstatementsarenotcorrect.35.Thenurseisnearingtheendofaninterview.Whichstatementisappropriateatthistime?a.Didweforgetsomething?b.Isthereanythingelseyouwouldliketomention?c.Ineedtogoontothenextpatient.Illbeback.d.WhileImhere,letstalkaboutyourupcomingsurgery.ANS:BThisquestionoffersthepersonafinalopportunityforself-expression.Nonewtopicshouldbeintroduced.Theotherquestionsarenotappropriate.36.Duringtheinterviewportionofdatacollection,thenursecollects__________data.a.Physicalb.Historicalc.Objectived.SubjectiveANS:DTheinterviewisthefirst,andreallythemostimportant,partofdatacollection.Duringtheinterview,thenursecollectssubjectivedata;thatis,whatthepersonsaysabouthimorherself.37.Duringaninterview,thenursewouldexpectthatmostoftheinterviewwilltakeplaceatwhatdistance?a.Intimatezone

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b.Personaldistancec.Socialdistanced.PublicdistanceANS:CSocialdistance,4to12feet,isusuallythedistancecategoryformostoftheinterview.Publicdistance,over12feet,istoomuchdistance;theintimatezoneisinappropriate,andthepersonaldistancewillbeusedforthephysicalassessment.38.Afemalenurseisinterviewingamalepatientwhoisnearthesameageasthenurse.Duringtheinterview,thepatientmakesanovertlysexualcomment.Thenursesbestreactionwouldbe:a.Stopthatimmediately!b.Oh,youaretoofunny.Letskeepgoingwiththeinterview.c.DoyoureallythinkIwouldbeinterested?d.Itmakesmeuncomfortablewhenyoutalkthatway.Pleasestop.ANS:DThenursesresponsemustmakeitclearthatsheisahealthprofessionalwhocanbestcareforthepersonbymaintainingaprofessionalrelationship.Atthesametime,thenurseshouldcommunicatethatheorsheacceptsthepersonandunderstandsthepersonsneedtobeself-assertivebutthatsexualadvancescannotbetolerated.MULTIPLERESPONSE1.Thenurseisconductinganinterview.Whichofthesestatementsistrueregardingopen-endedquestions?Selectallthatapply.a.Open-endedquestionselicitcoldfacts.b.Theyallowforself-expression.c.Open-endedquestionsbuildandenhancerapport.d.Theyleaveinteractionsneutral.e.Open-endedquestionscallforshortone-totwo-wordanswers.f.Theyareusedwhennarrativeinformationisneeded.ANS:B,C,FOpen-endedquestionsallowforself-expression,buildandenhancerapport,andobtainnarrativeinformation.Thesefeaturesenhancecommunicationduringaninterview.Theotherstatementsareappropriateforclosedordirectquestions.2.Thenurseisconductinganinterviewinanoutpatientclinicandisusingacomputertorecorddata.Whicharethebestusesofthecomputerinthissituation?Selectallthatapply.a.Collectthepatientsdatainadirect,face-to-facemanner.b.Enterallthedataasthepatientstatesthem.c.Askthepatienttowaitasthenurseentersthedata.d.Typethedataintothecomputerafterthenarrativeisfullyexplored.e.Allowthepatienttoseethemonitorduringtyping.

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ANS:A,D,ETheuseofacomputercanbecomeabarrier.Thenurseshouldbegintheinterviewasusualbygreetingthepatient,establishingrapport,andcollectingthepatientsnarrativestoryinadirect,face-to-facemanner.Onlyafterthenarrativeisfullyexploredshouldthenursetypedataintothecomputer.Whentyping,thenurseshouldpositionthemonitorsothatthepatientcanseeit.Chapter 2 Physical Examination StrategiesMULTIPLECHOICE1.Whenperformingaphysicalassessment,thefirsttechniquethenursewillalwaysuseis:a.Palpation.

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b.Inspection.c.Percussion.d.Auscultation.ANS:BTheskillsrequisiteforthephysicalexaminationareinspection,palpation,percussion,andauscultation.Theskillsareperformedoneatatimeandinthisorder(withtheexceptionoftheabdominalassessment,duringwhichauscultationtakesplacebeforepalpationandpercussion).Theassessmentofeachbodysystembeginswithinspection.Afocusedinspectiontakestimeandyieldsasurprisingamountofinformation.2.Thenurseispreparingtoperformaphysicalassessment.Whichstatementistrueaboutthephysicalassessment?Theinspectionphase:a.Usuallyyieldslittleinformation.b.Takestimeandrevealsasurprisingamountofinformation.c.Maybesomewhatuncomfortablefortheexpertpractitioner.d.Requiresaquickglanceatthepatientsbodysystemsbeforeproceedingwithpalpation.ANS:BAfocusedinspectiontakestimeandyieldsasurprisingamountofinformation.Initially,theexaminermayfeeluncomfortable,staringatthepersonwithoutalsodoingsomething.Afocusedassessmentissignificantlymorethanaquickglance.3.Thenurseisassessingapatientsskinduringanofficevisit.Whatpartofthehandandtechniqueshouldbeusedtobestassessthepatientsskintemperature?a.Fingertips;theyaremoresensitivetosmallchangesintemperature.b.Dorsalsurfaceofthehand;theskinisthinneronthissurfacethanonthepalms.c.Ulnarportionofthehand;increasedbloodsupplyinthisareaenhancestemperaturesensitivity.d.Palmarsurfaceofthehand;thissurfaceisthemostsensitivetotemperaturevariationsbecauseofitsincreasednervesupplyinthisarea.ANS:BThedorsa(backs)ofthehandsandfingersarebestfordeterminingtemperaturebecausetheskinisthinneronthedorsalsurfacesthanonthepalms.Fingertipsarebestforfine,tactilediscrimination.Theotherresponsesarenotusefulforpalpation.4.Whichofthesetechniquesusesthesenseoftouchtoassesstexture,temperature,moisture,andswellingwhenthenurseisassessingapatient?a.Palpationb.Inspectionc.Percussiond.AuscultationANS:A

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Palpationusesthesenseoftouchtoassessthepatientforthesefactors.Inspectioninvolvesvision;percussionassessesthroughtheuseofpalpablevibrationsandaudiblesounds;andauscultationusesthesenseofhearing.5.Thenurseispreparingtoassessapatientsabdomenbypalpation.Howshouldthenurseproceed?a.Palpationofreportedlytenderareasareavoidedbecausepalpationintheseareasmaycausepain.b.Palpatingatenderareaisquicklyperformedtoavoidanydiscomfortthatthepatientmayexperience.c.Theassessmentbeginswithdeeppalpation,whileencouragingthepatienttorelaxandtotakedeepbreaths.d.Theassessmentbeginswithlightpalpationtodetectsurfacecharacteristicsandtoaccustomthepatienttobeingtouched.ANS:DLightpalpationisinitiallyperformedtodetectanysurfacecharacteristicsandtoaccustomthepersontobeingtouched.Tenderareasshouldbepalpatedlast,notfirst.6.Thenursewouldusebimanualpalpationtechniqueinwhichsituation?a.Palpatingthethoraxofaninfantb.Palpatingthekidneysanduterusc.Assessingpulsationsandvibrationsd.AssessingthepresenceoftendernessandpainANS:BBimanualpalpationrequirestheuseofbothhandstoenveloporcapturecertainbodypartsororganssuchasthekidneys,uterus,oradnexa.Theothersituationsarenotappropriateforbimanualpalpation.7.Thenurseispreparingtopercusstheabdomenofapatient.Thepurposeofthepercussionistoassessthe__________oftheunderlyingtissue.a.Turgorb.Texturec.Densityd.ConsistencyANS:CPercussionyieldsasoundthatdepictsthelocation,size,anddensityoftheunderlyingorgan.Turgorandtextureareassessedwithpalpation.8.Thenurseisreviewingpercussiontechniqueswithanewlygraduatednurse.Whichtechnique,ifusedbythenewnurse,indicatesthatmorereviewisneeded?a.Percussingonceovereachareab.Quicklyliftingthestrikingfingeraftereachstrokec.Strikingwiththefingertip,notthefingerpadd.Usingthewristtomakethestrikes,notthearmANS:A

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Forpercussion,thenurseshouldpercusstwotimesovereachlocation.Thestrikingfingershouldbequicklyliftedbecausearestingfingerdampsoffvibrations.Thetipofthestrikingfingershouldmakecontact,notthepadofthefinger.Thewristmustberelaxedandisusedtomakethestrikes,notthearm.9.Whenpercussingovertheliverofapatient,thenursenoticesadullsound.Thenurseshould:a.Considerthisanormalfinding.b.Palpatethisareaforanunderlyingmass.c.Repositionthehands,andattempttopercussinthisareaagain.d.Considerthisfindingasabnormal,andreferthepatientforadditionaltreatment.ANS:APercussionoverrelativelydenseorgans,suchastheliverorspleen,willproduceadullsound.Theotherresponsesarenotcorrect.10.Thenurseisunabletoidentifyanychangesinsoundwhenpercussingovertheabdomenofanobesepatient.Whatshouldthenursedonext?a.Askthepatienttotakedeepbreathstorelaxtheabdominalmusculature.b.Considerthisfindingasnormal,andproceedwiththeabdominalassessment.c.Increasetheamountofstrengthusedwhenattemptingtopercussovertheabdomen.d.Decreasetheamountofstrengthusedwhenattemptingtopercussovertheabdomen.ANS:CThethicknessofthepersonsbodywallwillbeafactor.Thenurseneedsastrongerpercussionstrokeforpersonswithobeseorverymuscularbodywalls.Theforceoftheblowdeterminestheloudnessofthenote.Theotheractionsarenotcorrect.11.Thenursehearsbilateralloud,long,andlowtoneswhenpercussingoverthelungsofa4-year-oldchild.Thenurseshould:a.Palpateovertheareaforincreasedpainandtenderness.b.Askthechildtotakeshallowbreaths,andpercussovertheareaagain.c.Immediatelyreferthechildbecauseofanincreasedamountofairinthelungs.d.Considerthisfindingasnormalforachildthisage,andproceedwiththeexamination.ANS:DPercussionnotesthatareloudinamplitude,lowinpitch,ofaboomingquality,andlongindurationarenormaloverachildslung.12.Apatienthassuddenlydevelopedshortnessofbreathandappearstobeinsignificantrespiratorydistress.Aftercallingthephysicianandplacingthepatientonoxygen,whichoftheseactionsisthebestforthenursetotakewhenfurtherassessingthepatient?a.Countthepatientsrespirations.b.Bilaterallypercussthethorax,notinganydifferencesinpercussiontones.c.Callforachestx-raystudy,andwaitfortheresultsbeforebeginninganassessment.d.Inspectthethoraxforanynewmassesandbleedingassociatedwithrespirations.ANS:B

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Percussionisalwaysavailable,portable,andoffersinstantfeedbackregardingchangesinunderlyingtissuedensity,whichmayyieldcluesofthepatientsphysicalstatus.13.Thenurseisteachingaclassonbasicassessmentskills.Whichofthesestatementsistrueregardingthestethoscopeanditsuse?a.Slopeoftheearpiecesshouldpointposteriorly(towardtheocciput).b.Althoughthestethoscopedoesnotmagnifysound,itdoesblockoutextraneousroomnoise.c.Fitandqualityofthestethoscopearenotasimportantasitsabilitytomagnifysound.d.Idealtubinglengthshouldbe22inchestodampenthedistortionofsound.ANS:BThestethoscopedoesnotmagnifysound,butitdoesblockoutextraneousroomsounds.Theslopeoftheearpiecesshouldpointforwardtowardtheexaminersnose.Longtubingwilldistortsound.Thefitandqualityofthestethoscopearebothimportant.14.Thenurseispreparingtouseastethoscopeforauscultation.Whichstatementistrueregardingthediaphragmofthestethoscope?Thediaphragm:a.Isusedtolistenforhigh-pitchedsounds.b.Isusedtolistenforlow-pitchedsounds.c.Shouldbelightlyheldagainstthepersonsskintoblockoutlow-pitchedsounds.d.Shouldbelightlyheldagainstthepersonsskintolistenforextraheartsoundsandmurmurs.ANS:AThediaphragmofthestethoscopeisbestforlisteningtohigh-pitchedsoundssuchasbreath,bowel,andnormalheartsounds.Itshouldbefirmlyheldagainstthepersonsskin,firmlyenoughtoleavearing.Thebellofthestethoscopeisbestforsoft,low-pitchedsoundssuchasextraheartsoundsormurmurs.15.Beforeauscultatingtheabdomenforthepresenceofbowelsoundsonapatient,thenurseshould:a.Warmtheendpieceofthestethoscopebyplacingitinwarmwater.b.Leavethegownonthepatienttoensurethatheorshedoesnotgetchilledduringtheexamination.c.Ensurethatthebellsideofthestethoscopeisturnedtotheonposition.d.Checkthetemperatureoftheroom,andofferblanketstothepatientifheorshefeelscold.ANS:DTheexaminationroomshouldbewarm.Ifthepatientshivers,thentheinvoluntarymusclecontractionscanmakeitdifficulttoheartheunderlyingsounds.Theendofthestethoscopeshouldbewarmedbetweentheexaminershands,notwithwater.Thenurseshouldneverlistenthroughagown.Thediaphragmofthestethoscopeshouldbeusedtoauscultateforbowelsounds.16.Thenursewillusewhichtechniqueofassessmenttodeterminethepresenceofcrepitus,swelling,andpulsations?a.Palpationb.Inspectionc.Percussion

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d.AuscultationANS:APalpationappliesthesenseoftouchtoassesstexture,temperature,moisture,organlocationandsize,aswellasanyswelling,vibrationorpulsation,rigidityorspasticity,crepitation,presenceoflumpsormasses,andthepresenceoftendernessorpain.17.Thenurseispreparingtouseanotoscopeforanexamination.Whichstatementistrueregardingtheotoscope?Theotoscope:a.Isoftenusedtodirectlightontothesinuses.b.Usesashort,broadspeculumtohelpvisualizetheear.c.Isusedtoexaminethestructuresoftheinternalear.d.Directslightintotheearcanalandontothetympanicmembrane.ANS:DTheotoscopedirectslightintotheearcanalandontothetympanicmembranethatdividestheexternalandmiddleear.Ashort,broadspeculumisusedtovisualizethenares.18.Anexaminerisusinganophthalmoscopetoexamineapatientseyes.Thepatienthasastigmatismandisnearsighted.Theuseofwhichofthesetechniqueswouldindicatethattheexaminationisbeingcorrectlyperformed?a.Usingthelargefullcircleoflightwhenassessingpupilsthatarenotdilatedb.Rotatingthelensselectordialtotheblacknumberstocompensateforastigmatismc.Usingthegridonthelensaperturedialtovisualizetheexternalstructuresoftheeyed.RotatingthelensselectordialtobringtheobjectintofocusANS:DTheophthalmoscopeisusedtoexaminetheinternaleyestructures.Itcancompensatefornearsightednessorfarsightedness,butitwillnotcorrectforastigmatism.Thegridisusedtoassesssizeandlocationoflesionsonthefundus.Thelargefullspotoflightisusedtoassessdilatedpupils.Rotatingthelensselectordialbringstheobjectintofocus.19.Thenurseisunabletopalpatetherightradialpulseonapatient.Thebestactionwouldbeto:a.Auscultateovertheareawithafetoscope.b.Useagoniometertomeasurethepulsations.c.UseaDopplerdevicetocheckforpulsationsoverthearea.d.Checkforthepresenceofpulsationswithastethoscope.ANS:CDopplerdevicesareusedtoaugmentpulseorbloodpressuremeasurements.Goniometersmeasurejointrangeofmotion.Afetoscopeisusedtoauscultatefetalhearttones.Stethoscopesareusedtoauscultatebreath,bowel,andheartsounds.20.Thenurseispreparingtoperformaphysicalassessment.Thecorrectactionbythenurseisreflectedbywhichstatement?Thenurse:a.Performstheexaminationfromtheleftsideofthebed.b.Examinestenderorpainfulareasfirsttohelprelievethepatientsanxiety.c.Followsthesameexaminationsequence,regardlessofthepatientsageorcondition.

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d.Organizestheassessmenttoensurethatthepatientdoesnotchangepositionstoooften.ANS:DThestepsoftheassessmentshouldbeorganizedtoensurethatthepatientdoesnotchangepositionstoooften.Thesequenceofthestepsoftheassessmentmaydiffer,dependingontheageofthepersonandtheexaminerspreference.Tenderorpainfulareasshouldbeassessedlast.21.Amanisattheclinicforaphysicalexamination.Hestatesthatheisveryanxiousaboutthephysicalexamination.Whatstepscanthenursetaketomakehimmorecomfortable?a.Appearunhurriedandconfidentwhenexamininghim.b.Stayintheroomwhenheundressesincaseheneedsassistance.c.Askhimtochangeintoanexamininggownandtotakeoffhisundergarments.d.Defermeasuringvitalsignsuntiltheendoftheexamination,whichallowshimtimetobecomecomfortable.ANS:AAnxietycanbereducedbyanexaminerwhoisconfident,self-assured,considerate,andunhurried.Familiarandrelativelynonthreateningactions,suchasmeasuringthepersonsvitalsigns,willgraduallyaccustomthepersontotheexamination.22.Whenperformingaphysicalexamination,safetymustbeconsideredtoprotecttheexaminerandthepatientagainstthespreadofinfection.Whichofthesestatementsdescribesthemostappropriateactionthenurseshouldtakewhenperformingaphysicalexamination?a.Washingoneshandsafterremovingglovesisnotnecessary,aslongastheglovesarestillintact.b.Handsarewashedbeforeandaftereveryphysicalpatientencounter.c.Handsarewashedbeforetheexaminationofeachbodysystemtopreventthespreadofbacteriafromopartofthebodytoanother.d.Glovesarewornthroughouttheentireexaminationtodemonstratetothepatientconcernregardingthespreadofinfectiousdiseases.ANS:BThenurseshouldwashhisorherhandsbeforeandaftereveryphysicalpatientencounter;aftercontactwithblood,bodyfluids,secretions,andexcretions;aftercontactwithanyequipmentcontaminatedwithbodyfluids;andafterremovinggloves.Handsshouldbewashedaftergloveshavebeenremoved,eveniftheglovesappeartobeintact.Glovesshouldbewornwhenpotentialcontactwithanybodyfluidsispresent.23.Thenurseisexaminingapatientslowerlegandnoticesadrainingulceration.Whichoftheseactionsismostappropriateinthissituation?a.Washinghands,andcontactingthephysicianb.Continuingtoexaminetheulceration,andthenwashinghandsc.Washinghands,puttingongloves,andcontinuingwiththeexaminationoftheulcerationd.Washinghands,proceedingwithrestofthephysicalexamination,andthencontinuingwiththeexaminationofthelegulcerationANS:C

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Theexaminershouldweargloveswhenthepotentialcontactwithanybodyfluidsispresent.Inthissituation,thenurseshouldwashhisorherhands,putongloves,andcontinueexaminingtheulceration.24.Duringtheexamination,offeringsomebriefteachingaboutthepatientsbodyortheexaminersfindingsisoftenappropriate.Whichoneofthesestatementsbythenurseismostappropriate?a.Youratrialdysrhythmiasareundercontrol.b.Youhavepittingedemaandmildvaricosities.c.Yourpulseis80beatsperminute,whichiswithinthenormalrange.d.Imusingmystethoscopetolistenforanycrackles,wheezes,orrubs.ANS:CThesharingofsomeinformationbuildsrapport,aslongasthepatientisabletounderstandtheterminology.25.Thenursekeepsinmindthatthemostimportantreasontoshareinformationandtoofferbriefteachingwhileperformingthephysicalexaminationistohelpthe:a.Examinerfeelmorecomfortableandtogaincontrolofthesituation.b.Examinertobuildrapportandtoincreasethepatientsconfidenceinhimorher.c.Patientunderstandhisorherdiseaseprocessandtreatmentmodalities.d.Patientidentifyquestionsabouthisorherdiseaseandthepotentialareasofpatienteducation.ANS:BSharinginformationbuildsrapportandincreasesthepatientsconfidenceintheexaminer.Italsogivesthepatientalittlemorecontrolinasituationduringwhichfeelingcompletelyhelplessisoftenpresent.26.ThenurseisexamininganinfantandpreparestoelicittheMororeflexatwhichtimeduringtheexamination?a.Whentheinfantissleepingb.Attheendoftheexaminationc.Beforeauscultationofthethoraxd.HalfwaythroughtheexaminationANS:BTheMoroorstartlereflexiselicitedattheendoftheexaminationbecauseitmaycausetheinfanttocry.27.Whenpreparingtoperformaphysicalexaminationonaninfant,thenurseshould:a.Havetheparentremoveallclothingexceptthediaperonaboy.b.Instructtheparenttofeedtheinfantimmediatelybeforetheexamination.c.Encouragetheinfanttosuckonapacifierduringtheabdominalexamination.d.Asktheparenttoleavetheroombrieflywhenassessingtheinfantsvitalsigns.ANS:A

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Theparentshouldalwaysbepresenttoincreasethechildsfeelingofsecurityandtounderstandnormalgrowthanddevelopment.Thetimingoftheexaminationshouldbe1to2hoursafterfeedingwhenthebabyisneithertoodrowsynortoohungry.Infantsdonotobjecttobeingnude;clothingshouldberemoved,butadiapershouldbeleftonaboy.28.A6-month-oldinfanthasbeenbroughttothewell-childclinicforacheck-up.Sheiscurrentlysleeping.Whatshouldthenursedofirstwhenbeginningtheexamination?a.Auscultatethelungsandheartwhiletheinfantisstillsleeping.b.Examinetheinfantships,becausethisprocedureisuncomfortable.c.Beginwiththeassessmentoftheeye,andcontinuewiththeremainderoftheexaminationinahead-to-toeapproach.d.Waketheinfantbeforebeginninganyportionoftheexaminationtoobtainthemostaccurateassessmentofbodysystems.ANS:AWhentheinfantisquietorsleepingisanidealtimetoassessthecardiac,respiratory,andabdominalsystems.Assessmentoftheeye,ear,nose,andthroatareinvasiveproceduresthatshouldbeperformedattheendoftheexamination.29.A2-year-oldchildhasbeenbroughttotheclinicforawell-childcheckup.Thebestwayforthenursetobegintheassessmentisto:a.Asktheparenttoplacethechildontheexaminingtable.b.Havetheparentremoveallofthechildsclothingbeforetheexamination.c.Allowthechildtokeepasecurityobjectsuchasatoyorblanketduringtheexamination.d.Initiallyfocustheinteractionsonthechild,essentiallyignoringtheparentuntilthechildstrusthasbeenobtained.ANS:CThebestplacetoexaminethetoddlerisontheparentslap.Toddlersunderstandsymbols;therefore,asecurityobjectishelpful.Initially,thefocusismoreontheparent,whichallowsthechildtoadjustgraduallyandtobecomefamiliarwithyou.A2-year-oldchilddoesnotliketotakeoffhisorherclothes.Therefore,asktheparenttoundressonebodypartatatime.30.Thenurseisexamininga2-year-oldchildandasks,MayIlistentoyourheartnow?Whichcritiqueofthenursestechniqueismostaccurate?a.Askingquestionsenhancesthechildsautonomyb.Askingthechildforpermissionhelpsdevelopasenseoftrustc.Thisquestionisanappropriatestatementbecausechildrenatthisageliketohavechoicesd.Childrenatthisageliketosay,No.TheexaminershouldnotofferachoicewhennochoiceisavailableANS:DChildrenatthisageliketosay,No.Choicesshouldnotbeofferedwhennochoiceisreallyavailable.Ifthechildsays,Noandthenursedoesitanyway,thenthenurselosestrust.Autonomyisenhancedbyofferingalimitedoption,ShallIlistentoyourheartnextoryourtummy?

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31.Withwhichofthesepatientswoulditbemostappropriateforthenursetousegamesduringtheassessment,suchashavingthepatientblowoutthelightonthepenlight?a.Infantb.Preschoolchildc.School-agechildd.AdolescentANS:BWhenassessingpreschoolchildren,usinggamesorallowingthemtoplaywiththeequipmenttoreducetheirfearscanbehelpful.Suchgamesarenotappropriatefortheotheragegroups.32.Thenurseispreparingtoexaminea4-year-oldchild.Whichactionisappropriateforthisagegroup?a.Explaintheproceduresindetailtoalleviatethechildsanxiety.b.Givethechildfeedbackandreassuranceduringtheexamination.c.Donotaskthechildtoremovehisorherclothesbecausechildrenatthisageareusuallyveryprivate.d.Performanexaminationoftheear,nose,andthroatfirst,andthenexaminethethoraxandabdomen.ANS:BWithpreschoolchildren,short,simpleexplanationsshouldbeused.Childrenatthisageareusuallywillingtoundress.Anexaminationoftheheadshouldbeperformedlast.Duringtheexamination,neededfeedbackandreassuranceshouldbegiventothepreschooler.33.Whenexamininga16-year-oldmaleteenager,thenurseshould:a.Discusshealthteachingwiththeparentbecausetheteenisunlikelytobeinterestedinpromotingwellnb.Askhisparenttostayintheroomduringthehistoryandphysicalexaminationtoansweranyquestionsandtoalleviatehisanxiety.c.Talktohimthesamemannerasonewouldtalktoayoungerchildbecauseateenslevelofunderstandingmaynotmatchhisorherspeech.d.Providefeedbackthathisbodyisdevelopingnormally,anddiscussthewidevariationamongteenagersontherateofgrowthanddevelopment.ANS:DDuringtheexamination,theadolescentneedsfeedbackthathisorherbodyishealthyanddevelopingnormally.Theadolescenthasakeenawarenessofbodyimageandoftencompareshimorherselfwithpeers.Apprisetheadolescentofthewidevariationamongteenagersontherateofgrowthanddevelopment.34.Whenexamininganolderadult,thenurseshouldusewhichtechnique?a.Avoidtouchingthepatienttoomuch.b.Attempttoperformtheentirephysicalexaminationduringonevisit.c.Speakloudlyandslowlybecausemostagingadultshavehearingdeficits.d.Arrangethesequenceoftheexaminationtoallowasfewpositionchangesaspossible.

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ANS:DWhenexaminingtheolderadult,arrangingthesequenceoftheexaminationtoallowasfewpositionchangesaspossibleisbest.Physicaltouchisespeciallyimportantwiththeolderpersonbecauseothersensesmaybediminished.35.Themostimportantstepthatthenursecantaketopreventthetransmissionofmicroorganismsinthehospitalsettingisto:a.Wearprotectiveeyewearatalltimes.b.Wearglovesduringanyandallcontactwithpatients.c.Washhandsbeforeandaftercontactwitheachpatient.d.Cleanthestethoscopewithanalcoholswabbetweenpatients.ANS:CThemostimportantsteptodecreasetheriskofmicroorganismtransmissionistowashhandspromptlyandthoroughlybeforeandafterphysicalcontactwitheachpatient.Stethoscopesshouldalsobecleansedwithanalcoholswabbeforeandaftereachpatientcontact.Thebestroutineistocombinestethoscoperubbingwithhandhygieneeachtimehandhygieneisperformed.36.WhichofthesestatementsistrueregardingtheuseofStandardPrecautionsinthehealthcaresetting?a.StandardPrecautionsapplytoallbodyfluids,includingsweat.b.Usealcohol-basedhandrubifhandsarevisiblydirty.c.StandardPrecautionsareintendedforusewithallpatients,regardlessoftheirriskorpresumedinfectionstatus.d.StandardPrecautionsaretobeusedonlywhennonintactskin,excretionscontainingvisibleblood,orexpectedcontactwithmucousmembranesispresent.ANS:CStandardPrecautionsaredesignedtoreducetheriskoftransmissionofmicroorganismsfrombothrecognizedandunrecognizedsourcesandareintendedforuseforallpatients,regardlessoftheirriskorpresumedinfectionstatus.StandardPrecautionsapplytobloodandallotherbodyfluids,secretionsandexcretionsexceptsweatregardlessofwhethertheycontainvisibleblood,nonintactskin,ormucousmembranes.Handsshouldbewashedwithsoapandwaterifvisiblysoiledwithbloodorbodyfluids.Alcohol-basedhandrubscanbeusedifhandsarenotvisiblysoiled.37.Thenurseispreparingtoassessahospitalizedpatientwhoisexperiencingsignificantshortnessofbreath.Howshouldthenurseproceedwiththeassessment?a.Thepatientshouldliedowntoobtainanaccuratecardiac,respiratory,andabdominalassessment.b.Athoroughhistoryandphysicalassessmentinformationshouldbeobtainedfromthepatientsfamilymember.c.Acompletehistoryandphysicalassessmentshouldbeimmediatelyperformedtoobtainbaselineinformation.d.Bodyareasappropriatetotheproblemshouldbeexaminedandthentheassessmentcompletedaftertheproblemhasresolved.ANS:D

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Bothalteringthepositionofthepatientduringtheexaminationandcollectingaminidatabasebyexaminingthebodyareasappropriatetotheproblemmaybenecessaryinthissituation.Anassessmentmaybecompletedlaterafterthedistressisresolved.38.Whenexamininganinfant,thenurseshouldexaminewhichareafirst?a.Earb.Nosec.Throatd.AbdomenANS:DTheleast-distressingstepsareperformedfirst,savingtheinvasivestepsoftheexaminationoftheeye,ear,nose,andthroatuntillast.39.Whileauscultatingheartsounds,thenursehearsamurmur.Whichoftheseinstrumentsshouldbeusedtoassessthismurmur?a.Electrocardiogramb.Bellofthestethoscopec.Diaphragmofthestethoscoped.PalpationwiththenursespalmofthehandANS:BThebellofthestethoscopeisbestforsoft,low-pitchedsoundssuchasextraheartsoundsormurmurs.Thediaphragmofthestethoscopeisbestusedforhigh-pitchedsoundssuchasbreath,bowel,andnormalheartsounds.40.Duringanexaminationofapatientsabdomen,thenursenotesthattheabdomenisroundedandfirmtothetouch.Duringpercussion,thenursenotesadrumlikequalityofthesoundsacrossthequadrants.Thistypeofsoundindicates:a.Constipation.b.Air-filledareas.c.Presenceofatumor.d.Presenceofdenseorgans.ANS:BAmusicalordrumlikesound(tympany)isheardwhenpercussionoccursoveranair-filledviscus,suchasthestomachorintestines.41.Thenurseispreparingtoexaminea6-year-oldchild.Whichactionismostappropriate?a.Thethorax,abdomen,andgenitaliaareexaminedbeforethehead.b.Talkingabouttheequipmentbeingusedisavoidedbecausedoingsomayincreasethechildsanxiety.c.Thenurseshouldkeepinmindthatachildatthisagewillhaveasenseofmodesty.d.Thechildisaskedtoundressfromthewaistup.ANS:C

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A6-year-oldchildhasasenseofmodesty.Thechildshouldundresshimorherself,leavingunderpantsonandusingagownordrape.Aschool-agechildiscurioustoknowhowequipmentworks,andthesequenceshouldprogressfromthechildsheadtothetoes.42.Duringauscultationofapatientsheartsounds,thenursehearsanunfamiliarsound.Thenurseshould:a.Documentthefindingsinthepatientsrecord.b.Wait10minutes,andauscultatethesoundagain.c.Askthepatienthowheorsheisfeeling.d.Askanothernursetodoublecheckthefinding.ANS:DIfanabnormalfindingisnotfamiliar,thenthenursemayaskanotherexaminertodoublecheckthefinding.Theotherresponsesdonothelpidentifytheunfamiliarsound.MULTIPLERESPONSE1.Thenurseispreparingtopalpatethethoraxandabdomenofapatient.Whichofthesestatementsdescribesthecorrecttechniqueforthisprocedure?Selectallthatapply.a.Warmthehandsfirstbeforetouchingthepatient.b.Fordeeppalpation,useonelongcontinuouspalpationwhenassessingtheliver.c.Startwithlightpalpationtodetectsurfacecharacteristics.d.Usethefingertipstoexamineskintexture,swelling,pulsation,andpresenceoflumps.e.Identifyanytenderareas,andpalpatethemlast.f.Usethepalmsofthehandstoassesstemperatureoftheskin.ANS:A,C,D,EThehandsshouldalwaysbewarmedbeforebeginningpalpation.Intermittentpressureratherthanonelongcontinuouspalpationisused;anytenderareasareidentifiedandpalpatedlast.Fingertipsareusedtoexamineskintexture,swelling,pulsation,andthepresenceoflumps.Thedorsa(backs)ofthehandsareusedtoassessskintemperaturebecausetheskinonthedorsaisthinnerthanonthepalms.

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Advanced Health Assessment and Diagnostic Reasoning, 3rd Edition Test Bank - Page 27 preview image

Chapter 3 Documentation StrategiesMULTIPLECHOICE1.Thenurseisperformingageneralsurvey.Whichactionisacomponentofthegeneralsurvey?a.Observingthepatientsbodystatureandnutritionalstatusb.Interpretingthesubjectiveinformationthepatienthasreportedc.Measuringthepatientstemperature,pulse,respirations,andbloodpressured.ObservingspecificbodysystemswhileperformingthephysicalassessmentANS:AThegeneralsurveyisastudyofthewholepersonthatincludesobservingthepatientsphysicalappearance,bodystructure,mobility,andbehavior.2.Whenmeasuringapatientsweight,thenurseisawareofwhichoftheseguidelines?a.Thepatientisalwaysweighedwearingonlyhisorherundergarments.b.Thetypeofscaledoesnotmatter,aslongastheweightsaresimilarfromdaytoday.c.Thepatientmayleaveonhisorherjacketandshoesaslongasthesearedocumentednexttotheweighd.Attemptsshouldbemadetoweighthepatientatapproximatelythesametimeofday,ifasequenceofweightsisnecessary.ANS:DAstandardizedbalancescaleisusedtomeasureweight.Thepatientshouldremovehisorhershoesandheavyouterclothing.Ifasequenceofrepeatedweightsisnecessary,thenthenurseshouldattempttoweighthepatientatapproximatelythesametimeofdayandwiththesametypesofclothingworneachtime.3.Apatientsweeklybloodpressurereadingsfor2monthshaverangedbetween124/84mmHgand136/88mmHg,withanaveragereadingof126/86mmHg.Thenurseknowsthatthisbloodpressurefallswithinwhichbloodpressurecategory?a.Normalbloodpressureb.Prehypertensionc.Stage1hypertensiond.Stage2hypertensionANS:BAccordingtotheSeventhReportoftheJointNationalCommittee(JNC7)guidelines,prehypertensionbloodpressurereadingsaresystolicreadingsof120to139mmHgordiastolicreadingsof50to89mmHg.4.Duringanexaminationofachild,thenurseconsidersthatphysicalgrowthisthebestindexofachilds:a.Generalhealth.b.Geneticmakeup.c.Nutritionalstatus.d.Activityandexercisepatterns.ANS:A

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Physicalgrowthisthebestindexofachildsgeneralhealth;recordingthechildsheightandweighthelpsdeterminenormalgrowthpatterns.5.A1-month-oldinfanthasaheadmeasurementof34cmandhasachestcircumferenceof32cm.Basedontheinterpretationofthesefindings,thenursewould:a.Refertheinfanttoaphysicianforfurtherevaluation.b.Considerthesefindingsnormalfora1-month-oldinfant.c.Expectthechestcircumferencetobegreaterthantheheadcircumference.d.Asktheparenttoreturnin2weekstore-evaluatetheheadandchestcircumferences.ANS:BThenewbornsheadmeasuresapproximately32to38cmandisapproximately2cmlargerthanthechestcircumference.Between6monthsand2years,bothmeasurementsareapproximatelythesame,andafterage2years,thechestcircumferenceisgreaterthantheheadcircumference.6.Thenurseisassessingan80-year-oldmalepatient.Whichassessmentfindingswouldbeconsiderednormal?a.Increaseinbodyweightfromhisyoungeryearsb.Additionaldepositsoffatonthethighsandlowerlegsc.Presenceofkyphosisandflexioninthekneesandhipsd.Changeinoverallbodyproportion,includingalongertrunkandshorterextremitiesANS:CChangesthatoccurintheagingpersonincludemoreprominentbonylandmarks,decreasedbodyweight(especiallyinmen),adecreaseinsubcutaneousfatfromthefaceandperiphery,andadditionalfatdepositedontheabdomenandhips.Posturalchangesofkyphosisandslightflexioninthekneesandhipsalsooccur.7.Thenurseshouldmeasurerectaltemperaturesinwhichofthesepatients?a.School-agechildb.Olderadultc.Comatoseadultd.PatientreceivingoxygenbynasalcannulaANS:CRectaltemperaturesshouldbetakenwhentheotherroutesareimpractical,suchasforcomatoseorconfusedpersons,forthoseinshock,orforthosewhocannotclosethemouthbecauseofbreathingoroxygentubes,awiredmandible,orotherfacialdysfunctions.8.Thenurseispreparingtomeasurethelength,weight,chest,andheadcircumferenceofa6-month-oldinfant.Whichmeasurementtechniqueiscorrect?a.Measuringtheinfantslengthbyusingatapemeasureb.Weighingtheinfantbyplacinghimorheronanelectronicstandingscalec.Measuringthechestcircumferenceatthenipplelinewithatapemeasured.MeasuringtheheadcircumferencebywrappingthetapemeasureoverthenoseandcheekbonesANS:C

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Tomeasurethechestcircumference,thetapeisencircledaroundthechestatthenippleline.Thelengthshouldbemeasuredonahorizontalmeasuringboard.Weightshouldbemeasuredonaplatform-typebalancescale.Headcircumferenceismeasuredwiththetapearoundthehead,alignedattheeyebrows,andattheprominentfrontalandoccipitalbonesthewidestspaniscorrect.9.Thenurseknowsthatoneadvantageofthetympanicmembranethermometer(TMT)isthat:a.Rapidmeasurementisusefulforuncooperativeyoungerchildren.b.UsingtheTMTisthemostaccuratemethodformeasuringbodytemperatureinnewborninfants.c.MeasuringtemperatureusingtheTMTisinexpensive.d.StudiesstronglysupporttheuseoftheTMTinchildrenundertheage6years.ANS:ATheTMTisusefulforyoungchildrenwhomaynotcooperatefororaltemperaturesandfearrectaltemperatures.However,theuseaTMTwithnewborninfantsandyoungchildrenisconflicting.10.Whenassessinganolderadult,whichvitalsignchangesoccurwithaging?a.Increaseinpulserateb.Widenedpulsepressurec.Increaseinbodytemperatured.DecreaseindiastolicbloodpressureANS:BWithaging,thenursekeepsinmindthatthesystolicbloodpressureincreases,leadingtowidenedpulsepressure.Withmanyolderpeople,boththesystolicanddiastolicpressuresincrease.Thepulserateandtemperaturedonotincrease.11.Thenurseisexaminingapatientwhoiscomplainingoffeelingcold.Whichisamechanismofheatlossinthebody?a.Exerciseb.Radiationc.Metabolismd.FooddigestionANS:BThebodymaintainsasteadytemperaturethroughathermostatorfeedbackmechanism,whichisregulatedinthehypothalamusofthebrain.Thehypothalamusregulatesheatproductionfrommetabolism,exercise,fooddigestion,andexternalfactorswithheatlossthroughradiation,evaporationofsweat,convection,andconduction.12.Whenmeasuringapatientsbodytemperature,thenursekeepsinmindthatbodytemperatureisinfluencedby:a.Constipation.b.Patientsemotionalstate.c.Diurnalcycle.d.Nocturnalcycle.

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ANS:CNormaltemperatureisinfluencedbythediurnalcycle,exercise,andage.Theotherresponsesdonotinfluencebodytemperature.13.Whenevaluatingthetemperatureofolderadults,thenurseshouldrememberwhichaspectaboutanolderadultsbodytemperature?a.Thebodytemperatureoftheolderadultislowerthanthatofayoungeradult.b.Anolderadultsbodytemperatureisapproximatelythesameasthatofayoungchild.c.Bodytemperaturedependsonthetypeofthermometerused.d.Intheolderadult,thebodytemperaturevarieswidelybecauseoflesseffectiveheatcontrolmechanismANS:AInolderadults,thebodytemperatureisusuallylowerthaninotheragegroups,withameantemperatureof36.2C.14.A60-year-oldmalepatienthasbeentreatedforpneumoniaforthepast6weeks.Heisseentodayintheclinicforanunexplainedweightlossof10poundsoverthelast6weeks.Thenurseknowsthat:a.Weightlossisprobablytheresultofunhealthyeatinghabits.b.Chronicdiseasessuchashypertensioncauseweightloss.c.Unexplainedweightlossoftenaccompaniesshort-termillnesses.d.Weightlossisprobablytheresultofamentalhealthdysfunction.ANS:CAnunexplainedweightlossmaybeasignofashort-termillnessorachronicillnesssuchasendocrinedisease,malignancy,depression,anorexianervosa,orbulimia.15.Whenassessinga75-year-oldpatientwhohasasthma,thenursenotesthatheassumesatripodposition,leaningforwardwitharmsbracedonthechair.Onthebasisofthisobservation,thenurseshould:a.Assumethatthepatientiseagerandinterestedinparticipatingintheinterview.b.Evaluatethepatientforabdominalpain,whichmaybeexacerbatedinthesittingposition.c.Assumethatthepatientishavingdifficultybreathingandassisthimtoasupineposition.d.Recognizethatatripodpositionisoftenusedwhenapatientishavingrespiratorydifficulties.ANS:DAssumingatripodpositionleaningforwardwitharmsbracedonchairarmsoccurswithchronicpulmonarydisease.Theotheractionsorassumptionsarenotcorrect.16.Whichoftheseactionsillustratesthecorrecttechniquethenurseshouldusewhenassessingoraltemperaturewithamercurythermometer?a.Wait30minutesifthepatienthasingestedhotoricedliquids.b.Leavethethermometerinplace3to4minutesifthepatientisafebrile.c.Placethethermometerinfrontofthetongue,andaskthepatienttoclosehisorherlips.d.Shakethemercury-in-glassthermometerdowntobelow36.6Cbeforetakingthetemperature.ANS:B

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Thethermometershouldbeleftinplace3to4minutesifthepersonisafebrileandupto8minutesifthepersonisfebrile.Thenurseshouldwait15minutesifthepersonhasjustingestedhotoricedliquidsand2minutesifheorshehasjustsmoked.17.ThenurseistakingtemperaturesinaclinicwithaTMT.WhichstatementistrueregardinguseoftheTMT?a.Atympanictemperatureismoretimeconsumingthanarectaltemperature.b.Thetympanicmethodismoreinvasiveanduncomfortablethantheoralmethod.c.Theriskofcross-contaminationisreduced,comparedwiththerectalroute.d.Thetympanicmembranemostaccuratelyreflectsthetemperatureintheophthalmicartery.ANS:CTheTMTisanoninvasive,nontraumaticdevicethatisextremelyquickandefficient.Thechanceofcross-contaminationwiththeTMTisminimalbecausetheearcanalislinedwithskin,notmucousmembranes.18.Toassessarectaltemperatureaccuratelyinanadult,thenursewould:a.Usealubricatedblunttipthermometer.b.Insertthethermometer2to3inchesintotherectum.c.Leavethethermometerinplaceupto8minutesifthepatientisfebrile.d.Wait2to3minutesifthepatienthasrecentlysmokedacigarette.ANS:AAlubricatedrectalthermometer(withashort,blunttip)isinsertedonly2to3cm(1inch)intotheadultrectumandleftinplacefor2minutes.Cigarettesmokingdoesnotalterrectaltemperatures.19.Whichtechniqueiscorrectwhenthenurseisassessingtheradialpulseofapatient?Thepulseiscountedfor:a.1minute,iftherhythmisirregular.b.15secondsandthenmultipliedby4,iftherhythmisregular.c.2fullminutestodetectanyvariationinamplitude.d.10secondsandthenmultipliedby6,ifthepatienthasnohistoryofcardiacabnormalities.ANS:ARecentresearchsuggeststhatthe30-secondintervalmultipliedby2isthemostaccurateandefficienttechniquewhenheartratesarenormalorrapidandwhenrhythmsareregular.Iftherhythmisirregular,thenthepulseiscountedfor1fullminute.20.Whenassessingapatientspulse,thenurseshouldalsonoticewhichofthesecharacteristics?a.Forceb.Pallorc.Capillaryrefilltimed.TiminginthecardiaccycleANS:AThepulseisassessedforrate,rhythm,andforce.

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