what the person says about himself or herself during history taking
What you observe by inspecting, percussing, palpating, and auscultating during physical examination
Basing practice on the best available research evidence.
occurs when an individual identifies equally with two or more cultures
Process by which people of one culture merge into and become part of another culture
to examine a patient and provide appropriate care based around their cultural beliefs
concepts about health individuals belief are true. Influenced by culture
Pain that is caused by tissue injury
nociceptive
neuropathic
Questions that allow respondents to answer however they want
questions that specifically focus demanding either yes or no answers or answer specific options.
phases of the interview process
pre-interaction phase
beginning phase
working phase
closing phase
The sequence of actions that result in an effective interview
Narrative, flowcharts, diagrams, and other written materials that explain how a system works.
Influences during interview of aging adults
Culture
Ethnic and racial groups
Vulnerable populations
Religion and Spirituality
Screens the safety of independent living, the need for home health services, and quality of life
Effective therapeutic communication techniques
Developmental changes aging adult
Bp increase
HR increase
Arrhythmias increase
Cardiovascular disease
pain/sensitivity
Alert
Lethargic (somnolent)
Obtunded
Stupor or Semi-Coma
Coma
Delirium
Situation
Background
Assessment
Recommendation
Structured communication among the members of healthcare
Health history and objective data
What is observed by inspecting, percussing, palpating and auscultating
database
An organized collection of information.
communication methods with hearing impaired
Techniques of physical assessment
Inspection
Palpation
Percussion
Auscultation
Instrument used to examine the ear
funnels light into the ear canal and onto the tympanic membrane
Health Insurance Portability and Accountability Act
ethical standard that nurses are required to follow. not a law
professional health care that is culturally sensitive, appropriate, and competent
Traditions passed down from generation to generation
Subjective Data
What patient says about himself of herself during history taking
Objective Data
Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
Database
formed from above elements, plus patients record and laboratory studies
Steps of the Nursing Process
- Assessment
- Diagnosis
- Outcome identification
- Planning
- Implementation
- Evaluation
Assessment
-Review of clinical record
-interview
-health history
-physical exam
-functional assessment
-cultural and spiritual assessment
-consultation
-review of the literature
Diagnosis
-Interpretation of data by identifying clusters of cues so as to make inferences
-compare clusters of cues with definitions and defining characteristics
-validation of inferences based on findings
-identify related factors
-document the diagnosis
Outcome identification
-identify expected outcomes related to patient individualization
-ensure outcomes are realistic and measurable
-specify short term and long term goal measurement criteria
Planning
-Establish priorities on meeting identifies patient care goals
-develop outcomes and set time frames for meeting proposed outcomes
-identify relevant intervention and utilize interdisciplinary health care team members in the care planning process for the patient
-document plan of care
Implementation
-Determine patient readiness and involve pt
-review planned interventions with interdisciplinary health care team members to facilitate collaborative effort
-utilize principles of delegation, being mindful of supervision and evaluation
-counsel person and significant others
-refer to continuing care
-document care provided
Evaluation
-Refer to established outcomes
-Evaluate individual’s condition and compare actual outcomes with expected outcomes
-Summarize results of evaluation
-Identify reasons for failure to achieve expected outcomes
-Take corrective action to modify plan of care
-Document evaluation in plan of care
First level priority problems
Emergent, life threatening, and immediate
-airway
-breathing
-circulation
Second level priority problems
Next in urgency, requiring attention so as to avoid further deterioration
-mental status changes
-acute pain
-infection risk
-abnormal lab values
-elimination problems
Third level priority problems
Important to patient’s health but can be addressed after more urgent problems are addressed
-lack of knowledge
-mobility problems
-family coping
Four types of Data
- Complete total health database
- focused or problem centered database
- Follow up database
- Emergency database
Complete total health database
-Complete health history and full physical exam
-Describes current and past health state and forms baseline to measure all future changes
-yields diagnoses
Focused or problem centered database
-for limited of short term problems
-collect “mini” database, smaller scope and more focused than complete database
-concerns mainly one problem, one cue complex, or one body system
-history and examination follow direction of presenting concern
Follow up data base
Status of all identified problems should be evaluated at regular and appropriate intervals
-note changes that have occured
-evaluate whether problem is getting worse or better
-identify coping strategies being used
Emergency database
-Rapid collection of data, often compiled concurrently with lifesaving measures
-diagnosis must be rapid and comprehensive in nature
Describe rationale for providing culturally competent care.
Culturally competent implies that the caregivers understand and attend to the total context of the patient’s situation including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences.
Culture
the nonphysical attributes of a person – the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups
Socialization
the process of being raised within a culture and acquiring the characteristics of that group
Biomedical/scientific theory of illness
All events in life have a cause and effect
Naturalistic or holistic
believe that human life is only one aspect of nature and a part of the general order of the cosmos. Believe that the forces of nature must be kept in natural balance o or harmony
-perspective found most frequently among American Indians and Asians
Yin/Yang theory
-Health exists when all aspects of the person are in perfect balance
-Yin foods are cold, yang foods are hot.
-Basis for eastern of Chinese medicine
Hot/Cold theory
-Hispanic, Arab, and Asian groups embrace
- Treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness
Which statement best describes religion?
A. An organized system of beliefs concerning the cause, nature, and purpose of the universe
B. Belief in a divine or superhuman spirit to be obeyed and worshipeped
C. Affiliation with one of the 1200 recognized religions in the US
D. The following of established rituals, especially in conjunction with health seeking behaviors
A. an organized system of beliefs concerning the cause, nature, and purpose of the universe.
The major factor contributing to the need for cultural care nursing is:
a. an increasing birth rate
b. limited access to health care services
c. demographic change
d. a decreasing rate in immigration
C. demographic change
The term culturally competent implies that the nurse
a. is prepared in nursing
b. possesses knowledge of the traditions of diverse peoples
c. applies underlying knowledge to providing nursing care
d. understands the cultural context of the patient’s situation
D. understands the cultural context of the patient’s situation
You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your knowledge of linguistic competence, which action would present as a barrier to effective communication?
a. maintaining a professional respectful demeanor
b. allowing for additional time to complete process
c. providing the patient with a paper and pencil so he or she can write down the answers to the questions that you are going to ask
d. seeing if there are any family members present who may assist with the interview process
C. Providing the patient with a paper and pencil so he or she can write down the answers to the questions that you are going to ask.
Which culture would describe illness as hot and cold imbalance?
a. asian american
b. african american
c. hispanic-american
d. american-indian
C. Hispanic American
Of what does the patient believe the amulet is protective?
a. the evil eye
b. being kidnapped
c. exposure to bacterial infections
d. an unexpected fall
a. the evil eye
Which statement best illustrates the difference between religion and spirituality?
a. Religion reflects an individual’s reaction to life events whereas spirituality is based on whether the individual attends religious services
b. religion is characterized by identification of a higher being shaping one’s destiny, whereas spirituality reflects an individual’s perception of one’s life having worth or meaning
c. religion is the expression of spiritual awakening whereas spirituality is based on belief in divine right.
d. religion is the active interpretation of one’s spirituality
B.
The first step to cultural competency by a nurse is to:
a. identify the meaning of health to the patient
b. understand how a heath care delivery system works
c. develop a frame of reference to traditional health care practices
d. understand your own heritage and its basis in cultural values
D. understand your own heritage and its basis in cultural values
Which statement is true in regard to pain?
a. Nurse’s attitude’s toward their patients’ pain are unrelated to their own experiences with pain
b. The cultural background of a patient is important in a nurse’s assessment of that patient’s pain.
c. A nurse’s area of clinical practice is most likely to determine his or her assessment of a patient’s pain.
d. A nurse’s years of clinical experience and current position are a strong indicator of his or her response to patient pain.
b. The cultural background of a patient is important in a nurse’s assessment of that patient’s pain.
Which factor is identified as a priority influence on a patient’s health status?
a. poverty
b. lifestyle factors
c. legislative action
d. occupational status
a. poverty
Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indiana patient?
a. “Are you of the Christian faith?”
b. “Do you want to see a medicine man?”
c. “How often do you seek help from medical providers?”
d. “What cultural or spiritual beliefs are important to you?”
d. What cultural or spiritual beliefs are important to you?
Which statement best describes ethnocentrism?
a. The government’s description of various cultures
b. A central belief that accepts all cultures as one’s own
c. The tendency to view your own way of life as the most desirable
d. The tendency to impose your beliefs, values, and patterns of behaviors on an individual from another culture
c. The tendency to view your own way of life as the most desirable
Which category is appropriate in a cultural assessment?
a. family history
b. chief complaint
c. past medical history
d. health related beliefs
d. health related beliefs
Which health belief practice is associated with patients who are American Indian heritage?
a. Wearing bangle bracelets to ward off evil spirits
b. Believing that forces of nature must be kept in natural balance
c. Using a swamp root as a traditional home remedy
d. Believing in a shaman as a traditional healer
b. Believing that forces of nature must be kept in natural balance
Which statement best reflects the Magicoreligious causation of illness?
a. Each being is but a part of a larger structure in the world of nature as it relates to health and illness.
b. Causality relationship exists, leading to expression of illness
c. Belief in the struggle between good and evil is reflected in the regulation of health and illness
d. illness occurs as a result of disturbances between hot and cold reactions
C. Belief in the struggle bw good and evil is reflected in the regulation of health and illness
Acculturation
process of adapting the culture and behavior of the majority culture
Assimilation
process of developing a new cultural identity and becoming like members of dominant culture
Biculturalism
dual pattern of identification and often of divided loyalty
Starting the interview
-time and place of interview and physical exam
-intro of and explanation of health care providers role
-purpose of interview
-how long it will take
-expectation of participation for each person
-presence of others (family etc)
-confidentiality and to what extent it may be limited
-any costs to the patient
Sending communication is
-behavior, conscious or unconscious, verbal and nonverbal
-all behavior has meaning
-body language: posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place chair
Receiving communication is
receiver attaches meaning determined by his or her past experiences, culture, self-concept, and current physical and emotional state
Internal factors of communication
liking others, empathy, ability to listen
external factors to communication
Ensure privacy, refuse interruptions, physical environment, dress, note taking, tape and video recording
When to use open ended questions
- to begin interview
- to introduce a new section of questions
- when ever the patient introduces a new topic
When to use close of direct questions
-after opening narrative to fill in details person may have left out
- when you need many specific facts about past health problems or during review of systems
- to move the interview along
Ten Traps of Interviewing
- providing false assurance or reassurance
- giving unwanted advice
- using authority
- using avoidance language
- engaging in distancing
- using professional jargon
- using leading or biased questions
- talking too much
- interrupting
- using “why” questions
Symptom
Subjective sensation person feels from disorder
- what person says is reason for seeking care is recorded and enclosed in quotation marks to indicate person’s exact words
Sign
objective abnormality that can be detected on physical exam or in lab reports
Final summary of any symptom should have these eight critical characteristics
- location
- character or quality
- quantity or severity
- timing
- setting
- aggravating or relieving factors
- associated factors
- patient’s perception
PQRSTU Mnemonic
P = Provocative or palliative
Q = Quality or quantity
R = Region or radiation
S = Severity scale: 1 to 10
T = Timing or onset
U = Understand patient’s perception of problem
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is:
a. excited about her pregnancy but nervous about the labor
b. exhibiting verbal and nonverbal behaviors that do not match
c. excited about her pregnancy, but her husband s not and this is upsetting her
d. not excited about her pregnancy but believes the nurse will negatively respond to her if she states this
b. exhibiting verbal and nonverbal behaviors that do not match
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
a.Well-adjusted adolescent who came in for a sports physical
b. Recovering alcoholic who came in for a basic physical examination
c. Man whose wife has just been diagnosed with lung cancer
d. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him
C. man whose wife has just been diagnosed with lung cancer
The nurse makes which adjustment in the physical environment to promote the success of an interview?
a. Reduces noise by turning off televisions and radios
b. Reduces the distance between the interviewer and the patient to 2 feet or less
c. Provides a dim light that makes the room cozy and helps the patient relax
d. Arranges seating across a desk or table to allow the patient some personal space
a. reduces noise by turning off televisions and radios
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
a.
Note-taking may impede the nurses observation of the patients nonverbal behaviors.
b.
Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
c.
Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
d.
Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
a. note taking may impede the nurses observation of the patients nonverbal behaviors
The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __ phase of the interview process.
a.
Summary
b.
Closing
c.
Body
d.
Opening or introduction
d. opening or introduction
A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?
a.
Hello, Nancy, my name is Mrs. C.
b.
Hello, Mrs. H., my name is Mrs. C. It sure is cold today!
c.
Mrs. H., my name is Mrs. C. How are you?
d.
Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.
d. Mrs H, my name is Mrs. C. I’ll need to ask you a few questions about what happened
During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement?
a.
Reflection
b.
Facilitation
c.
Direct question
d.
Open-ended question
d. open ended question
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
a.
Mr. Y., at your age, surely you have been hospitalized before!
b.
Mr. Y., I just need permission to get your medical records from County Medical.
c.
Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?
d.
Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?
d. Mr Y, I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?
In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be:
a.
Empathy.
b.
Reflection.
c.
Facilitation.
d.
Confrontation.
D. confrontation
When the health care provider uses the response of confrontation, the frame of reference shifts from the patients perspective to the perspective of the health care provider, and the health care provider starts to express his or her own thoughts and feelings. Empathy, reflection, and facilitation responses focus on the patients frame of reference.
When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior?
a.
Be silent, and allow him to continue when he is ready.
b.
Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these pains.
c.
Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there?
d.
Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time.
a. be silent, and allow him to continue when he is ready
A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be:
a.
Go on, Im listening.
b.
Fits? Tell me what you mean by this.
c.
Yes, it can be upsetting when a child has a fit.
d.
Dont be upset when he has a fit; every 2 year old has fits.
b. Fits? Tell me what you mean by this.
The nurse should use clarification when the persons word choice is ambiguous or confusing (e.g., Tell me what you mean by fits.). Clarification is also used to summarize the persons words or to simplify the words to make them clearer; the nurse should then ask if he or she is on the right track.
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy?
a.
You feel alone.
b.
You cant believe he left you alone?
c.
It must be so hard to face this all alone.
d.
I would be angry, too; raising a child alone is no picnic.
c. It must be hard to face this all alone.
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
a.
Mr. K., I know that you are lying.
b.
Mr. K., come on, tell me how much you smoke.
c.
Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that.
d.
Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.
d. Mr. K, you have said that you dont smoke, but I see you have an open pack of cigarettes in your pocket
The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to:
a.
Apologize, because using interpretation can be demeaning for the patient.
b.
Allow time for the patient to confirm or correct the inference.
c.
Continue with the interview as though nothing has happened.
d.
Immediately restate the nurses conclusion on the basis of the patients nonverbal response.
b. allow time for the patient to confirm or correct the inference
During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be:
a.
You are going to leave him?
b.
If you are afraid for your children, then why cant you leave?
c.
It sounds as if you might be afraid of how your husband will respond.
d.
It sounds as though you have made your decision. I think it is a good one.
c. it sounds as if you might be afraid of how your husband will respond
A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a:
a.
Therapeutic response. By sharing something personal, the nurse gives hope to this woman.
b.
Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears.
c.
Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman.
d.
Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.
b. Nontheraoeutic responce. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears
During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be:
a.
Id quit if I were you. The doctor really knows what he is talking about.
b.
Would you like some information about the different ways a person can quit smoking?
c.
Stopping your dependence on cigarettes can be very difficult. I understand how you feel.
d.
Why are you confused? Didnt the doctor give you the information about the smoking cessation program we offer?
b. Would you like some information about the different ways a person can quit smoking?
As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner:
a.
Youre afraid you might lose your breast?
b.
No, Im not sure what you are talking about.
c.
Ill wait here until you get yourself under control, and then we can talk.
d.
I can see that you are very upset. Perhaps we should discuss this later.
a. You’re afraid you might lose your breast?
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of:
a.
Talking too much.
b.
Using confrontation.
c.
Using biased or leading questions.
d.
Using blunt language to deal with distasteful topics.
c. using biased or leading questions
When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
a.
Ask someone who knows the patient well to help interpret this discrepancy.
b.
Focus on the patients verbal message, and try to ignore the nonverbal behaviors.
c.
Try to integrate the verbal and nonverbal messages and then interpret them as an average.
d.
Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.
d. focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:
a.
Simply changing positions.
b.
More comfortable in this position.
c.
Tired and needs a break from the interview.
d.
Uncomfortable talking about his sons treatment.
d. uncomfortable talking about his sons treatment
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
a.
Tickle the toddler, and get her to laugh.
b.
Stoop down to her level, and ask her about the toy she is holding.
c.
Continue to ignore her until it is time for the physical examination.
d.
Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.
b. stoop down to her level, and ask her about the toy she is holding
During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation?
a.
Tell the child that the blood pressure cuff is going to give her arm a big hug.
b.
Tell the child that the blood pressure cuff is asleep and cannot wake up.
c.
Give the blood pressure cuff a name and refer to it by this name during the assessment.
d.
Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.
d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are
A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him?
a.
Use periods of silence to communicate respect for him.
b.
Be totally honest with him, even if the information is unpleasant.
c.
Tell him that everything that is discussed will be kept totally confidential.
d.
Use slang language when possible to help him open up.
b. be totally honest with him, even if the information is unpleasant
A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this?
a.
An aged person has a longer story to tell.
b.
An aged person is usually lonely and likes to have someone with whom to talk.
c.
Aged persons lose much of their mental abilities and require longer time to complete an interview.
d.
As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said.
a. an aged person has a longer story to tell
The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?
a.
Determine the communication method he prefers.
b.
Avoid using facial and hand gestures because most hearing-impaired people find this degrading.
c.
Request a sign language interpreter before meeting with him to help facilitate the communication.
d.
Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.
a. determine the communication method he prefers
During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be:
a.
Im so sorry for making you cry!
b.
I can see that you are sad remembering this. It is all right to cry.
c.
Why dont I step out for a few minutes until youre feeling better?
d.
I can see that you feel sad about this; why dont we talk about something else?
d. I can see that you are sad remembering this. It is all right to cry.
A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next?
a.
The nurse should try to relax; these behaviors are culturally appropriate for this person.
b.
The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview.
c.
These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors.
d.
The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away.
a. the nurse should try to relax; these behaviors are culturally appropriate for this person
A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation?
a.
The woman is nervous and embarrassed.
b.
She has something to hide and is ashamed.
c.
The woman is showing inconsistent verbal and nonverbal behaviors.
d.
She is showing that she is carefully listening to what the nurse is saying.
d. she is showing that she is carefully listening to what the nurse is saying
Eye contact is perhaps among the most culturally variable nonverbal behaviors. Asian, American Indian, Indochinese, Arabian, and Appalachian people may consider direct eye contact impolite or aggressive, and they may avert their eyes during the interview. American Indians often stare at the floor during the interview, which is a culturally appropriate behavior, indicating that the listener is paying close attention to the speaker.
The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?
a.
Do you take medicine?
b.
Do you sterilize the bottles?
c.
Do you have nausea and vomiting?
d.
You have been taking your medicine, havent you?
a. do you take medicine?
A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview?
a.
How is your family?
b.
How is your job?
c.
Tell me about your hypertension.
d.
How has your health been since your last visit?
d. how has your health been since your last visit?
The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment?
a.
This comment is inappropriate because it shows the nurses bias.
b.
This comment is appropriate because members of the health care team are experts in their area of patient care.
c.
This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation.
d.
Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.
c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation
A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
a.
Trained interpreter
b.
Male family member
c.
Female family member
d.
Volunteer college student from the foreign language studies department
a. trained interpreter
During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question?
a.
This question may place the patient on the defensive.
b.
This question is an innocent search for information.
c.
Discussing his behavior with his wife would have been better.
d.
A direct question is the best way to discover the reasons for his behavior.
a. this question may place the patient on the defensive
The nurse is nearing the end of an interview. Which statement is appropriate at this time?
a.
Did we forget something?
b.
Is there anything else you would like to mention?
c.
I need to go on to the next patient. Ill be back.
d.
While Im here, lets talk about your upcoming surgery.
b. is there anything else you would like to mention?
During the interview portion of data collection, the nurse collects __ data.
a.
Physical
b.
Historical
c.
Objective
d.
Subjective
d. subjective
During an interview, the nurse would expect that most of the interview will take place at what distance?
a.
Intimate zone
b.
Personal distance
c.
Social distance
d.
Public distance
c. social distance
(personal distance is used for physical assessment)
A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be:
a.
Stop that immediately!
b.
Oh, you are too funny. Lets keep going with the interview.
c.
Do you really think I would be interested?
d.
It makes me uncomfortable when you talk that way. Please stop.
d. it makes me uncomfortable when you talk that way. Please stop.
The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply.
a.
Open-ended questions elicit cold facts.
b.
They allow for self-expression.
c.
Open-ended questions build and enhance rapport.
d.
They leave interactions neutral.
e.
Open-ended questions call for short one- to two-word answers.
f.
They are used when narrative information is needed.
b c f
The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation? Select all that apply.
a.
Collect the patients data in a direct, face-to-face manner.
b.
Enter all the data as the patient states them.
c.
Ask the patient to wait as the nurse enters the data.
d.
Type the data into the computer after the narrative is fully explored.
e.
Allow the patient to see the monitor during typing.
a, d, e
The nurse is preparing discharge planning for a hospitalized patient. When should the nurse start discharge teaching?
a. the nurse should start discharge teaching upon admission.
b. the nurse should wait until just before discharge to start teaching so the patient will remember instructions
c. the nurse should wait for the doctor to write the orders for discharge
d. the doctor will provide discharge teaching
a. the nurse should start discharge teaching upon admission