CH 09

[Osborn] chapter 9
Learning Outcomes [Number and Title]

Learning Outcome 1
Describe the components of the health assessment.
Learning Outcome 2
Explain the steps of the patient interview for the health history.
Learning Outcome 3
Compare and contrast verbal and nonverbal responses that enhance the
collection of information.
Learning Outcome 4
Explain how the techniques of inspection, palpation, percussion, and
auscultation can be applied to the physical assessment of the major body
systems.
Learning Outcome 5
Differentiate between the steps of the critical thinking component as it
relates to health assessment.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
1. While conducting a health assessment, the nurse documents a patients response under the heading
chief complaint. The nurse is currently conducting the _____________ part of the health
assessment.
1.
2.
3.
4.
History of present illness

Past medical history
Family history
Psychosocial history
Correct Answer: History of present illness

Rationale: The history of the present illness includes information about what brought the patient to the
health care provider. By using open-ended questioning, the nurse can obtain the reason why the patient
is seeking care. The reason is usually written verbatim in the health record and often becomes the chief
complaint. The chief complaint is not included in the past medical history, family history, or
psychosocial history.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 1
2. A patient comes to the emergency department and states, I am having chest pain and I feel short of
breath. The data the patient has just given the nurse is considered as which of the following?
1.
2.
3.
4.
Subjective
Objective
Factual
Nonspecific
Correct Answer: Subjective

Rationale: Subjective data is information that the patient provides to the nurse. Objective data is
information collected by using the senses with the techniques of observation, palpation, auscultation,
percussion, and smell. Factual and nonspecific are not identified types of data.
LO: 1
3. The nurse has completed collecting data from a patient. After the nurse analyzes this data, the next
action is to:
1.
2.
3.
4.
Formulate nursing diagnoses.

Plan care.
Determine patient care goals.
Evaluate outcomes from care.
Correct Answer: Formulate nursing diagnoses.

Rationale: Once data is collected, the information is used to formulate nursing diagnoses or the step that
is done after the assessment within the nursing process. The other choices represent additional steps
within the nursing process that occur after nursing diagnoses are formulated.
Cognitive Level: Applying
LO: 1
4. The nurse asks the patient, What brings you to the hospital today? The nurse uses this type of
question because:
1.
2.
3.
4.
It is useful for introducing a subject in general terms.

It will provide specific information.
It helps to clarify information.
It acknowledges agreement between the patient and the nurse.
Correct Answer: It is useful for introducing a subject in general terms.

Rationale: The question what brings you to the hospital today? is an open-ended question and asks for
narrative information by stating the topic in general terms. It is used to introduce a topic. Direct
questions are used to provide specific information. The question does not help to clarify information nor
acknowledge agreement between the patient and the nurse.
LO: 2
5. While conducting a health history, the nurse nods her head as the patient is talking. This gesture is
primarily used to:
1.
2.
3.
4.
Encourage the patient to continue talking.

Allow the nurse time to observe the patients nonverbal cues.
Reduce the patients anxiety level.
Acknowledge the patients feelings.
Correct Answer: Encourage the patient to continue talking.

Rationale: Nodding the head encourages the patient to tell the nurse more and is considered facilitation.
The use of silence will allow the nurse time to observe the patients nonverbal cues; the nurse may nod
her head in silence, but the goal of nodding is to encourage the patient, not to allow for observation.
Explanation will reduce the patients anxiety level. Empathy is used to acknowledge the patients
feelings.
LO: 2
6. A patient tells the nurse that he has a history of back pain that is controlled with yoga and herbal
supplements. The nurse realizes this information is most likely considered as a part of:
1.
2.
3.
4.
Cultural beliefs and practices.

Spiritual beliefs.
Western medicine.
Stress reduction.
Correct Answer: Cultural beliefs and practices.

Rationale: The patient is describing an alternative method to treat a health problem, which is a part of
cultural beliefs and practices within the health history. Spiritual beliefs include practices such as
omitting specific foods, care of the hair, and belief in God. Western medicine is the type of health care
traditionally provided in the United States and includes diagnostic testing, treatments, and medications.
Stress reduction is activities done to reduce the impact of stress on the body, such as meditation and
deep breathing. Although yoga and herbal supplements might be included as stress-reduction techniques,
the patient specifically stated that he uses these activities to reduce back pain, which means they are a
cultural belief and practice.
LO: 2
7. The nurse introduces herself and shakes the patients hand, then sits so that eye contact can be
maintained during the health interview. The nurses actions demonstration which of the following?
1.
2.
3.
4.
Positive nonverbal messages

Negative nonverbal messages
Empathy
Facilitation
Correct Answer: Positive nonverbal messages

Rationale: Positive nonverbal messages enhance the relationship with the patient and include eye contact
and equal-status seating. Negative nonverbal messages include tense posture, yawning, and avoiding eye
contact. Empathy is acknowledging a patients feelings with a statement of understanding. Facilitation
would be if the nurse would nod the head in effort to encourage the patient to continue talking.
LO: 3
8. During the health history, a patient tells the nurse that she is in an abusive relationship and is fearful
of getting hurt if her husband finds out that she told the nurse. Which of the following responses by the
nurse is most appropriate for this patient?
1.
2.
3.
4.
Are you saying that you are in danger?

Dont worry. They only strike back when they are angry.
I would get an attorney if I were you.
Remember, what goes around comes around.
Correct Answer: Are you saying that you are in danger?

Rationale: The nurse needs to clarify what the patient is explaining, and the best response would be for
the nurse to clarify if the client is saying she is in danger. The other responses are inappropriate and
would not provide support to the patient or help clarify what the patient is describing to the nurse.
Nursing Process: Implementation
Client Need: Psychosocial Integrity
LO: 3
9. During an assessment, the patient describes shoulder pain. The nurse responds, So, you have this
shoulder pain when you eat fried foods or ice cream, is that correct? The nurse is utilizing which of the
following techniques while assessing the patient?
1.
2.
3.
4.
Interpretation
Facilitation
Empathy
Summary
Correct Answer: Interpretation

Rationale: Interpretation links events or implies a cause, which is what the nurse is doing when
responding to this patient. Facilitation is a technique that would encourage the patient to continue
talking. Empathy acknowledges the patients feelings with a statement of understanding to help the
patient feel accepted. Summary occurs at the end of the interview and is when the nurse summarizes the
perception of the patients health problem from the information gained during the interview.
LO: 3
10. The nurse notices a patient has a strong foul body odor. When asked about his hygiene abilities, the
patient tells the nurse he has trouble getting in and out of the bathtub. Which areas of the physical
assessment does this information address?
1.
2.
3.
4.
Functional assessment, physical appearance, and mobility

Nutritional assessment, mental status, and behavior
Behavior and pain
Physical appearance, height, and weight
Correct Answer: Functional assessment, physical appearance, and mobility

Rationale: The patient states difficulty with using a bathtub, which provides information for the
functional assessment, physical appearance, and mobility. The inability to use the bathtub does not
provide information about the patients nutritional status, mental status, behavior, pain, height, or
weight.
LO: 4
11. Prior to conducting a physical assessment with a patient, the nurse puts on a pair of gloves. The
patient asks, What are the gloves for? Which is the best response the nurse can give the patient?
1. Gloves are considered a standard precaution to provide protection to the health care provider
during an exam.
2. The gloves help me to grip my equipment better.
3. I dont want to catch anything from you.
4. I prefer to wear gloves when touching people.
Correct Answer: Gloves are considered a standard precaution to provide protection to the health care
provider during an exam.
Rationale: The nurse needs to use standard precautions throughout the entire physical examination and
should make this statement to the patient. The other responses are not appropriate or are an incorrect
reason for wearing gloves during a physical examination.
LO: 4
12. While conducting a physical examination, the nurse elicits the tone tympany. Which of the following
structures is the nurse most likely currently assessing?
1.
2.
3.
4.
Intestines
Lungs
Liver
Bone
Correct Answer: Intestines

Rationale: Tympany is a high-pitched drum-like sound commonly heard over the intestines. Resonance
is a loud hollow tone commonly heard over the lungs. Dullness is a high-pitched tone heard over the
liver. Flatness is a soft-pitched tone heard over bone.
LO: 4
13. A patient in the unit has a blood pressure of 55/30, is lethargic, has slurred speech, and is unable to
get up from the floor unassisted. The nurse calls for a rapid response team. Which component of
critical thinking is the nurse exhibiting?
1.
2.
3.
4.
Analysis of situation, distinguishing normal from abnormal

Evaluation of situation, determination of outcomes achieved
Collection of information, subjective and objective
Selection of alternative by developing outcomes and plans
Correct Answer: Analysis of situation, distinguishing normal from abnormal

Rationale: Analysis of the situation is the second component of critical thinking. This component
includes the ability of the nurse to distinguish normal from abnormal. Evaluation of the situation is the
last step of the critical thinking process and is used to determine if the expected outcomes have been
achieved. Collection of information is the first step in the critical thinking process and is used during
the health assessment. Selection of alternatives is the fourth step in the critical thinking process and is
used when developing outcomes and plans.
Client Need: Physiological Integrity
LO: 5
14. The nurse is discussing with the patient a variety of options that can be used to help alleviate a health
problem. The step of the critical thinking process that the nurse and patient are currently engaged in
would be:
1.
2.
3.
4.
Generation of alternatives.
Collection of information.
Evaluation.
Analysis of the situation.
Correct Answer: Generation of alternatives.

Rationale: Generation of alternatives is when options are identified and priorities are established. The
nurse and patient work together to discuss the options so the patient can make an informed decision.
Collection of information begins with the interview and continues throughout the entire health
assessment. Evaluation is the last step and is done to determine if the expected outcomes have been
achieved. Analysis of the situation is done after the collection of information and helps distinguish
normal from abnormal findings.
LO: 5
15. The nurse is reviewing the outcomes of a patients plan of care. When working through this phase
of the critical thinking process, the nurse will use ____________ to determine the patients outcomes.
1.
2.
3.
4.
Every step of the critical thinking process

Collection of information and generation of alternatives
Selection of alternatives and analysis of the situation
Analysis of the situation and generation of alternatives
Correct Answer: Every step of the critical thinking process

Rationale: The last step in the critical thinking process is evaluation. Evaluation requires the nurse to
determine if the expected outcomes have been achieved. Every step of critical thinking is used here to
determine if any omissions or misinterpretations occurred.
LO: 5

CH 09

Transféré par

Informations du document

Description originale:

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

CH 09

Transféré par

Droits d'auteur :

Formats disponibles

[Osborn] chapter 9

Learning Outcomes [Number and Title]

History of present illness

Correct Answer: History of present illness

Correct Answer: Subjective

Formulate nursing diagnoses.

Correct Answer: Formulate nursing diagnoses.

It is useful for introducing a subject in general terms.

Correct Answer: It is useful for introducing a subject in general terms.

Encourage the patient to continue talking.

Correct Answer: Encourage the patient to continue talking.

Cultural beliefs and practices.

Correct Answer: Cultural beliefs and practices.

Positive nonverbal messages

Correct Answer: Positive nonverbal messages

Are you saying that you are in danger?

Correct Answer: Are you saying that you are in danger?

Correct Answer: Interpretation

Functional assessment, physical appearance, and mobility

Correct Answer: Functional assessment, physical appearance, and mobility

Correct Answer: Intestines

Analysis of situation, distinguishing normal from abnormal

Correct Answer: Analysis of situation, distinguishing normal from abnormal

Correct Answer: Generation of alternatives.

Every step of the critical thinking process

Correct Answer: Every step of the critical thinking process

Vous aimerez peut-être aussi