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Advanced Health Assessment and Differential Diagnosis Essentials for Clinical Practice 1st Edition Myrick Test Bank

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Advanced Health Assessment and Differential Diagnosis Essentials for Clinical Practice 1st Edition Myrick Test Bank Chapter 1. Health History, The Patient Interview, And Motivational Interviewing M... ULTIPLE CHOICE 1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a . To provide an opportunity for interaction between the patient and the nurse b . To provide a form for obtaining the patients biographic information c . To document the normal and abnormal findings of a physical assessment d . To provide a database of subjective information about the patients past andcurrent health ANS: D The purpose of the health history is to collect subjective datawhat the person says about him or herself. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 49 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: a . Has a history of drug abuse and therefore is not reliable. b . Provided consistent information and therefore is reliable. c . Smiled throughout interview and therefore is assumed reliable. d . Would not answer questions concerning stress and therefore is not reliable. ANS: B A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct. DIF: Cognitive Level: Applying (Application) REF: dm. 49MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care? a . J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b . J.M. came into the clinic complaining of having black stools for the past 24 hours. c . J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d . J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours. ANS: D The reason for seeking care is a brief spontaneous statement in the persons own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the persons exact words. DIF: Cognitive Level: Applying (Application) REF: dm. 50 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response? a . Can you point to where it hurts? b . Well talk more about that later in the interview. c . What have you had to eat in the last 24 hours? d . Have you ever had any surgeries on your abdomen? ANS: A A final summary of any symptom the person has should include, along with seven other critical characteristics, Location: specific. The person is asked to point to the location. DIF: Cognitive Level: Applying (Application) REF: dm. 50 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the womans statement?a . How does your family react to your pain? b . The pain must be terrible. You probably pinched a nerve. c . Ive had back pain myself, and it can be excruciating. d . How would you say the pain affects your ability to do your daily activities? ANS: D The symptom of pain is difficult to quantify because of individual interpretation. With pain, adjectives should be avoided and the patient should be asked how the pain affects his or her daily activities. The other responses are not appropriate. DIF: Cognitive Level: Applying (Application) REF: dm. 50 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a . Patient denies usual childhood illnesses. b . Patient states he was a very healthy child. c . Patient states his sister had measles, but he didnt. d . Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. ANS: D Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording usual childhood illnesses because an illness common in the persons childhood may be unusual today (e.g., measles). DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 51 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a P-6, B-4, (S)Ab-2 .b . Grav 6, Term 4, (S)Ab-2, Living 4 c . Patient has had four living babies. d . Patient has been pregnant six times. ANS: B Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav Term Preterm Ab Living . For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion. DIF: Cognitive Level: Applying (Application) REF: dm. 51 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information? a Are you allergic to any other drugs? . b How often have you received penicillin? . c Ill write your allergy on your chart so you wont receive any penicillin. . d Describe what happens to you when you take penicillin. . ANS: D Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic reaction. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 52 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a Emphysema. .b . Head trauma. c . Mental illness. d . Fractured bones. ANS: C Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis should be asked. DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 53-54 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. The review of systems provides the nurse with: a Physical findings related to each system. . b Information regarding health promotion practices. . c An opportunity to teach the patient medical terms. . d Information necessary for the nurse to diagnose the patients medical problem. . ANS: B The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices. DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 54 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin? a Skin appears dry. . b No lesions are obvious. .c Patient denies any color change. . d Lesion is noted on the lateral aspect of the right arm. . ANS: C The history should be limited to patient statements or subjective datafactors that the person says were or were not present. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 54 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a Do you perform testicular self-examinations? . b Have you ever noticed any pain in your testicles? . c Have you had any problems with passing urine? . d Do you have any history of sexually transmitted diseases? . ANS: A Health promotion for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 56 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a . I broke my right leg in a car accident 2 weeks ago. b . The pain is decreasing, but I still need to take acetaminophen. c . I check the color of my toes every evening just like I was taught.d Im able to transfer myself from the wheelchair to the bed without help. . ANS: D Functional assessment measures a persons self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues. DIF: Cognitive Level: Applying (Application) REF: dm. 56 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a . This has been a difficult year for you. b . I dont know how anyone could handle that much stress in 1 year! c . What did you do to cope with the loss of both your husband and mother? d . That is a lot of stress; now lets go on to the next section of your history. ANS: C Questions about coping and stress management include questions regarding the kinds of stresses in ones life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful. DIF: Cognitive Level: Applying (Application) REF: dm. 57 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a . This information is necessary to determine the patients reliability. b . Alcohol can interact with all medications and can make some diseases worse. c . The nurse needs to be able to teach the patient about the dangers of alcohol use. d . This information is not necessary unless a drinking problem is obvious. ANS: BAlcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 58 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a . Maybe she is just teething. b . I will check her ear for an ear infection. c . Are you sure she is really having pain? d . Describe what she is doing to indicate she is having pain. ANS: D With a very young child, the parent is asked, How do you know the child is in pain? A young child pulling at his or her ears should alert parents to the childs ear pain. Statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination. 17. 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? ANS: B Clarification should be used when the persons word choice is ambiguous or confusing. 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. The other responses giveunwanted advice or do not offer a helpful response. DIF: Cognitive Level: Applying (Application) REF: dm. 33 MSC: Client Needs: Psychosocial Integrity 18. 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. ANS: A Reflection echoes the patients words, repeating part of what the person has just said. Reflection can also help express the feelings behind a persons words. DIF: Cognitive Level: Applying (Application) REF: dm. 33 MSC: Client Needs: Psychosocial Integrity 19. 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. ANS: C This question is an example of using leading or biased questions. Asking, You dont smoke, do you? implies that one answer is better than another. If the person wants to please someone, then he or she is either forced to answer in a way that corresponds to his or her implied values or is made to feel guilty when admitting the other answer.DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 34 MSC: Client Needs: Psychosocial Integrity 20. 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. ANS: D When nonverbal and verbal messages are congruent, the verbal message is reinforced. When they are incongruent, the nonverbal message tends to be the true one because it is under less conscious control. Thus studying the nonverbal messages of the patients and examiners and understanding their meanings are important. The other statements are not true. DIF: Cognitive Level: Applying (Application) REF: dm. 28 MSC: Client Needs: Psychosocial Integrity 21. 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. ANS: D The persons position is noted. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Any change in posture should be noted. If a person in a relaxed position suddenly tenses, then this change in posture suggestspossible discomfort with the new topic. DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 35 MSC: Client Needs: Psychosocial Integrity 22. 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. ANS: B Although most of the communication is with the parent, the nurse should not completely ignore the child. Making contact will help ease the toddler later during the physical examination. The nurse should begin by asking about the toys the child is playing with or about a special doll or teddy bear brought from home. Does your doll have a name? or What can your truck do? Stoop down to meet the child at his or her eye level. DIF: Cognitive Level: Applying (Application) REF: dm. 37 MSC: Client Needs: Psychosocial Integrity 23. 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. ANS: D Take the time to give a short, simple explanation with a concrete explanation for any unfamiliarequipment that will be used on the child. Preschoolers are animistic; they imagine inanimate objects can come alive and have human characteristics. Thus a blood pressure cuff can wake up and bite or pinch. DIF: Cognitive Level: Applying (Application) REF: dm. 38-39 MSC: Client Needs: Psychosocial Integrity 24. 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. ANS: B Successful communication with an adolescent is possible and can be rewarding. The guidelines are simple. The first consideration is ones attitude, which must be one of respect. Second, communication must be totally honest. An adolescents intuition is highly tuned and can detect phoniness or the withholding of information. Always tell him or her the truth. DIF: Cognitive Level: Applying (Application) REF: dm. 39 MSC: Client Needs: Psychosocial Integrity 25. 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. ANS: A The interview usually takes longer with older adults because they have a longer story to tell. It is not necessarily true that all older adults are lonely, have lost mental abilities, or are hard ofhearing. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 40 MSC: Client Needs: Psychosocial Integrity 26. 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. ANS: A The nurse should ask the deaf person the preferred way to communicateby signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him squarely and have good lighting on the nurses face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and supplement his or her voice with appropriate hand gestures or pantomime. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 41 MSC: Client Needs: Psychosocial Integrity 27. 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? ANS: B A beginning examiner usually feels horrified when the patient starts crying. When the nurse sayssomething that makes the person cry, the nurse should not think he or she has hurt the person. The nurse has simply hit on an important topic; therefore, moving on to a new topic is essential. The nurse should allow the person to cry and to express his or her feelings fully. The nurse can offer a tissue and wait until the crying subsides to talk. DIF: Cognitive Level: Applying (Application) REF: dm. 42 MSC: Client Needs: Psychosocial Integrity 28. 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. ANS: A Both the patients and the nurses sense of spatial distance are significant throughout the interview and physical examination, with culturally appropriate distance zones varying widely. Some cultural groups value close physical proximity and may perceive a health care provider who is distancing him or herself as being aloof and unfriendly. DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 29 MSC: Client Needs: Psychosocial Integrity 29. 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.ANS: D 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. DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 36 MSC: Client Needs: Psychosocial Integrity 30. 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? ANS: A In a situation during which a language barrier exists and no interpreter is available, simple words should be used, avoiding medical jargon. The use of contractions and pronouns should also be avoided. Nouns should be repeatedly used, and one topic at a time should be discussed. DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 46 MSC: Client Needs: Psychosocial Integrity 31. 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? . ANS: D Open-ended questions are used for gathering narrative information. This type of questioning should be used to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. DIF: Cognitive Level: Applying (Application) REF: dm. 31 MSC: Client Needs: Psychosocial Integrity 32. 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. ANS: C Using authority responses promotes dependency and inferiority. Avoiding the use of authority is best. Although the health care provider and patient do not have equal professional knowledge, both have equally worthy roles in the health process. The other statements are not correct. DIF: Cognitive Level: Applying (Application) REF: dm. 34 MSC: Client Needs: Psychosocial Integrity 33. 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 departmentANS: A Whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 44 MSC: Client Needs: Psychosocial Integrity 34. 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. ANS: A The adults use of why questions usually implies blame and condemnation and places the person on the defensive. The other statements are not correct. DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 34 MSC: Client Needs: Psychosocial Integrity 35. 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. ANS: B This question offers the person a final opportunity for self-expression. No new topic should be introduced. The other questions are not appropriate.DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 36 MSC: Client Needs: Psychosocial Integrity 36. During the interview portion of data collection, the nurse collects data. a Physical . b Historical . c Objective . d Subjective . ANS: D The interview is the first, and really the most important, part of data collection. During the interview, the nurse collects subjective data; that is, what the person says about him or herself. DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 27 MSC: Client Needs: Psychosocial Integrity 37. 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 ANS: C Social distance, 4 to 12 feet, is usually the distance category for most of the interview. Public distance, over 12 feet, is too much distance; the intimate zone is inappropriate, and the personal distance will be used for the physical assessment. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 29 MSC: Client Needs: Psychosocial Integrity 38. 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. ANS: D The nurses response must make it clear that she is a health professional who can best care for the person by maintaining a professional relationship. At the same time, the nurse should communicate that he or she accepts the person and understands the persons need to be selfassertive but that sexual advances cannot be tolerated. Chapter 2. Advanced Health Assessment of the Head, Neck, and Lymphatic System MULTIPLE CHOICE 1. A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a . Just above the diaphragm. b . Just lateral to the knee cap. c . At the level of the C7 vertebra. d . At the level of the T11 vertebra. ANS: C The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed. DIF: Cognitive Level: Applying (Application) REF: dm. 251 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 2. A mother brings her 2-month-old daughter in for an examination and says, My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong? The nurses best response would be:a . Perhaps that could be a result of your dietary intake during pregnancy. b . Your baby may have craniosynostosis, a disease of the sutures of the brain. c . That soft spot may be an indication of cretinism or congenital hypothyroidism. d . That soft spot is normal, and actually allows for growth of the brain during the first year of your babys life. ANS: D Membrane-covered soft spots allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years. DIF: Cognitive Level: Applying (Application) REF: dm. 255 MSC: Client Needs: Health Promotion and Maintenance 3. The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a III . b V . c VII . d VIII . ANS: C Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy). DIF: Cognitive Level: Applying (Application) REF: dm. 259 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 4. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a Bell palsy. .b . Damage to the trigeminal nerve. c . Frostbite with resultant paresthesia to the cheeks. d . Scleroderma. ANS: B Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem. DIF: Cognitive Level: Applying (Application) REF: dm. 252-253 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 5. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the and glands. a Occipital; submental . b Parotid; jugulodigastric . c Parotid; submandibular . d Submandibular; occipital . ANS: C Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 253 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN and proceeds with the examination by . a XI; palpating the anterior and posterior triangles .b . XI; asking the patient to shrug her shoulders against resistance c . XII; percussing the sternomastoid and submandibular neck muscles d . XII; assessing for a positive Romberg sign ANS: B The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotat