Principles of Clinical Interviewing and Physical Assessment for Nursing Students, Exams of Nursing

Download Principles of Clinical Interviewing and Physical Assessment for Nursing Students and more Exams Nursing in PDF only on Docsity! HAP Exam 1 Questions With 100% Correct Verified Answers A student nurse recognizes a hospitalized patient as the neighbor of a close friend. When the student sees the friend next , the student says, "You know that older man who lives in the apartment next to you? Well, I took care of him today in the hospital". The student nurse is not respecting which of the following principles? a. Fidelity b. Benevolence c. Confidentiality d. Veracity - C. Confidentiality When recording information for the review of systems, the interviewer must document: a. the presence or absence of all symptoms under the system heading. b. objective data that supports the history of present illness. c. "negative" under the system heading. d. physical findings, such as skin appearance, to support historic data. - a. the presence or absence of all symptoms under the system heading. The nurse is conducting a heath history on an adult patient. Which technique can facilitate open communication between the patient and the nurse? a. Stand about 1 foot away from the patient's stretcher. b. Sit on a chair that is 4 feet away from the patient's stretcher. c. Sit on the stretcher next to the patient. d. Stand about 12 feet away from the patient's stretcher. - b. Sit on a chair that is 4 feet away from the patient's stretcher. Which phase of the interview uses communication techniques to collect health data? a. Preinteraction Phase b. Working phase c. Closing phase d. Beginning phase - b. Working phase OLDCARTS is a mnemonic that helps the clinician to remember to address characteristics specific to: a. symptoms. b. substance use and abuse. c. severity of dementia. d. the ability to perform activities of daily living (ADLs). - a. symptoms The most appropriate introduction to use to start an interview with an adult patient is: a. "David, I am here to ask you questions about your illness; we want to determine what is wrong." b. "Because so many people have already asked you questions, I will just get the information from the chart." c. "Mr. Jones, I am going to ask you some questions about your health so that we can plan your care." d. "Mr. Jones, is it okay if I ask you some quick questions this morning about your health?" - c. "Mr. Jones, I am going to ask you some questions about your health so that we can plan your care." The nurse is caring for a patient who is scheduled for surgery. The nurse observes that the patient appears anxious. Which of the following responses from the nurse is appropriate? a. "Why did you wait so long to make an appointment?" b. "That is exactly how I would feel." c. "Tell me how you feel about having surgery." d. "If I were you, I would have the surgery." - c. "Tell me how you feel about having surgery." A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about: a. relieving (alleviating) factors. b. the patient's perception of pain. c. aggravating factors. d. the nature or character of the headache. - c. aggravating factors Spirituality is defined as: a. participating in religious services on a regular basis. b. a social group that claims to possess variable traits. c. the process of being raised within a culture. d. a personal effort to find meaning and purpose in life. - d. a personal effort to find meaning and purpose in life What is one way nurses use critical thinking in regard to the nursing process? a. Nurses do not need to think critically; they just need to follow orders b. Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions. c. Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular patient. d. Critical thinking allows nurses to make decisions regarding patient care without involving the patient in decisions. - b. Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions. To perform an accurate assessment of heart rate, the examiner can do which of the following? Select all that apply: a. Increased vascularity of the skin in the elderly b. Increased numbers of sweat and sebaceous glands in the elderly c. An increase in elasticity and an increase in subcutaneous fat in the elderly d. An increased loss of elasticity and a decrease in subcutaneous fat in the elderly - d. An increased loss of elasticity and a decrease in subcutaneous fat in the elderly A patient tells the nurse that they noticed that a mole has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? a. Symmetry of lesions b. Diameter less than 6 mm c. Border regularity d. Color variation - d. color variation The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: a. papule. b. wheal. c. nodule. d. bulla. - a. papule The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? a. Childhood growth spurts b. Severe obesity c. Connective tissue disorders such as scleroderma d. Severe dehydration - d. severe dehydration The nurse observes that clubbing of the nails was documented by the previous nurse. What finding should the nurse expect upon assessing the patient? a. a nail base that is firm and slightly tender. b. curved nails with a convex profile and ridges across the nail. c. a nail base that feels spongy with an angle of the nail base of 150 degrees. d. an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. - d. an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. While inspecting the skin, a nurse notices a lesion on the patient's upper right arm. What is the best way to document the size of this lesion? a. Estimate its size to the nearest inch. b. Use a centimeter ruler to measure the lesion. c. Trace the lesion onto a piece of paper. d. Compare its size to the size of a coin. - b. Use a centimeter ruler to measure the lesion. A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure injury on the patient's left trochanter area that involves partial-thickness skin loss with no damage to the subcutaneous tissue. The nurse reports this pressure injury as which stage? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 - b. Stage 2 Most facial bones articulate at a suture. Which facial bone articulates at a joint? a. Maxilla b. Nasal bone c. Mandible d. Zygomatic bone - c. Mandible The nurse is assessing a patient's visual acuity. Which of the following statements is true in regard to the patient's results obtained from use of the Snellen chart? a. The smaller the denominator, the poorer the vision. b. The larger the denominator, the poorer the vision. c. The larger the numerator, the better the vision. d. The smaller the numerator, the poorer the vision. - b. The larger the denominator, the poorer the vision. The nurse is assessing a patient's extraocular muscles. Which of the following is most important for the nurse to remember about extraocular movements? a. Decreased in the elderly. b. Stimulated by cranial nerves III, IV, and VI. c. Impaired in a patient with cataracts. d. Stimulated by cranial nerves I and II. - b. Stimulated by cranial nerves III, IV, and VI. The nurse is testing a patient's visual accommodation, which refers to which action? a. Involuntary blinking in the presence of bright light b. Changes in peripheral vision in response to light c. Pupillary dilation when looking at a near object d. Pupillary constriction when looking at a near object - d. Pupillary constriction when looking at a near object When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose. - c. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? a. I just could not keep my balance when I sat up." b. "I felt faint like I was going to pass out." c. "It seemed that the room was spinning around." d. "I was afraid that I was going to lose consciousness." - c. "It seemed that the room was spinning around." Which of the following behaviors demonstrated by an individual may be indicative of hearing loss? a. Not looking at the examiner when being questioned b. Frequently asking for the question to be repeated c. Talking in a high-pitched voice d. Speaking slowly with well-articulated consonants - b. Frequently asking for the question to be repeated The external structure of the ear is identified as the: a. auriga. b. atrium. c. aureole. d. auricle. - d. auricle Which test provides a precise quantitative measure of hearing? a. Romberg test b. Audioscope test c. Tuning fork tests d. Whispered voice test - b. Audioscope test In performing a whispered voice test to assess hearing, which of these actions would the nurse do? (SELECT ALL THAT APPLY) a. Ensure that the patient cannot see the examiner's lips. b. Whisper a set of random numbers and letters and ask the patient to repeat them. c. Stand about 2 feet away directly in front of the patient. d. Repeat using different numbers and letters if their first response is not correct. - a,b,d When assessing a patient's lungs, the nurse recalls that the left lung: a. consists primarily of an upper lobe on the posterior chest. b. consists of two lobes. c. is shorter than the right lung because of the underlying stomach. d. is divided by the horizontal fissure. - b. consists of two lobes.