Question One

1. Question One Because the physical environment in which an interview takes place is an important consideration for the success of an interview, the interviewer should:

2. Question One Choices • reduce noise by turning off televisions and radios. • make eye contact only when asking a question. • provide a dim light that makes the room cozy to help the patient relax. • arrange seating across a desk or table to allow the patient some personal space.

3. Question One Response • reduce noise by turning off televisions and radios. • make eye contact only when asking a question. • provide a dim light that makes the room cozy to help the patient relax. • arrange seating across a desk or table to allow the patient some personal space.

4. Question One Rationale Correct answer: Turning off televisions and radios helps to prevent distractions during the interview.

5. Question One Rationale Option 2: Incorrect, because the nurse should maintain eye contact as much as possible while interviewing. Option 3: Incorrect, because the room should have good lighting so observations can be made during the interview. Option 4: Incorrect, because placing a desk or table between the nurse and the patient creates a sense of separation and limits communication.

6. Question Two Which of the following statements best describes the purpose of a health history?

7. Question Two Choices To provide an opportunity for interaction between patient and nurse To provide a form for obtaining the patient’s biographic information To document the normal and abnormal findings of a physical assessment To provide a database of subjective information about the patient’s past and current health

8. Question Two Response To provide an opportunity for interaction between patient and nurse To provide a form for obtaining the patient’s biographic information To document the normal and abnormal findings of a physical assessment To provide a database of subjective information about the patient’s past and current health

9. Question Two Rationale Correct answer: The health history provides subjective information for the patient database about past and current health.

10. Question Two Rationale Option 1: Incorrect, because the purpose of the health history is to obtain subjective information for the database, not to have personal interactions. Option 2: Incorrect, because biographic information is only one element of the health history. Option 3: Incorrect, because the health history and physical assessment are two different pieces of the health assessment.

11. Question Three Which would be correct statements about the focused interview? (Select all that apply.)

12. Question Three Choices The focused interview is a time when nurses use critical thinking. The focused interview enables the nurse to obtain more information from the patient. The focused interview always follows the physical examination. The focused interview allows the nurse to follow up on nonverbal cues. The focused interview provides client teaching about treatment.

13. Question Three Response The focused interview is a time when nurses use critical thinking. The focused interview enables the nurse to obtain more information from the patient. The focused interview always follows the physical examination. The focused interview allows the nurse to follow up on nonverbal cues. The focused interview provides client teaching about treatment.

14. Question Three Rationale Correct answer: Option 1 The nurse uses critical thinking in the focused interview to decide what more information is needed from the patient. Option 2 The focused interview enables the nurse to ask more specific questions and get a clearer picture of the problem. Option 4 The nurse can ask more about nonverbal cues in the focused interview.

15. Question Three Rationale Option 3: Incorrect, because the focused interview helps to guide the physical examination, which follows it. Option 5: Incorrect, because the focused interview gathers more information so that diagnosis and treatment can be determined. Then client teaching would occur.

16. Question Four From the list below, select the documentation sample that is the best:

17. Question Four Choices Oral temperature (Fahrenheit) 99.2, plus or minus 0.2 degrees. Patient was irritable and rude to staff. T 98.6F (oral), P 80, R 20, BP 110/70 and headache 6 on scale of 0 to 10 reported over intercom to nursing station T 99.6F (rectal), P 60, R 18, BP 128/80; complaint of “mild nausea since breakfast”

18. Question Four Response Oral temperature (Fahrenheit) 99.2, plus or minus 0.2 degrees. Patient was irritable and rude to staff. T 98.6F (oral), P 80, R 20, BP 110/70 and headache 6 on scale of 0 to 10 reported over intercom to nursing station T 99.6F (rectal), P 60, R 18, BP 128/80; complaint of “mild nausea since breakfast”

19. Question Four Rationale Correct answer: Temperature, pulse, respirations, blood pressure, and report of subjective symptoms are all accurate, appropriate, detailed data.

20. Question Four Rationale Option 1: Incorrect, because recorded measurements must be accurate. Option 2: Incorrect, because “irritable and obnoxious” are subjective impressions, not data; the nurse should state facts rather than opinions or interpretations of observations. Option 3: Incorrect, because patient information is confidential; privacy must be maintained.

21. Question Five The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history?

22. Question Five Choices “Why did you come to the United States?” “When did you come to the United States, and from what country?” “What made you leave your native country?” “Are you planning to return to your home?”

23. Question Five Response “Why did you come to the United States?” “When did you come to the United States, and from what country?” “What made you leave your native country?” “Are you planning to return to your home?”

24. Question Five Rationale Correct answer: The timing of entry and the country of origin can be important pieces of information in identifying a health condition.

25. Question Five Rationale Option 1: Incorrect, because the patient’s reason for coming to this country is generally not needed for treatment. Option 3: Incorrect, because the patient’s reason for leaving a country is not necessary information for a health history. Option 4: Incorrect, because the patient’s intention of returning to their country of origin is generally not relevant information.