Chapter 16 Nursing Assessment: Patient Interview Answers

Question 1 of 12

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When the nurse enters the patient’s room and says, “Hi, my name is Barbara. I am your nurse. Let’s discuss why you have been admitted to the hospital,” which phase of the patient interview is taking place?

Working
The working phase is used to gather information from the patient. The nursing introduction and purpose are covered during the orientation phase.

Transition
The transition phase is not considered a phase of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. The nursing introduction and purpose are covered during the orientation phase.

Correct

Orientation
The nursing introduction and purpose are covered during the orientation phase of the interview.

Termination
The termination phase is used to let the patient know what to expect next and give the patient a chance to ask any questions. The nursing introduction and purpose are covered during the orientation phase.

Question 2 of 12

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Which patient interview phase would the nurse implement when obtaining the patient’s prior medical history?

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Working
Health history information is obtained during the working phase.

Transition
The transition phase is not considered a phase of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Health history information is obtained during the working phase.

Orientation
The orientation phase is used as an introduction and determines the purpose of the interview. Health history information is obtained during the working phase.

Termination
The termination phase is used to let the patient know what to expect next and give the patient a chance to ask any questions. Health history information is obtained during the working phase.

Question 3 of 12

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The nurse states, “You have a long history of asthma, and the symptoms have been much worse lately; do you have anything else to share with me before you see the health care provider?” Which patient interview phase is taking place?

Working
The working phase is used to gather information from the patient. Summation and patient questions are included in the termination phase.

Transition
The transition phase is not considered a phase of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Summation and patient questions are included in the termination phase.

Orientation
The orientation phase is used as an introduction and determines the purpose of the interview. Summation and patient questions are included in the termination phase.

Correct

Termination
The termination phase is the last phase of the interview, and it focuses on preparation of the patient to end the discussion. Summation and patient questions are included in the termination phase.

Question 4 of 12

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Which categories comprise the primary components of the general survey?

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Mobility

Mobility is a component of the general survey and involves gait and range of motion.

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Behavior

Behavior is a component of the general survey, encompassing facial expression, mood and affect, speech, dress, and personal hygiene.

Correct

Body structure

Body structure is a component of the general survey, involving stature, nutrition, symmetry, posture, position, and body build.

Emotional health

Although observable behaviors can reveal some information about this aspect of the patient, emotional health is not considered one of the four primary components of the general survey.

Correct

Physical appearance

Physical appearance is a component of the general survey and includes age, sex, level of consciousness, and facial features.

Chapter 16, Nursing Assessment Patient Interview Answers Question 5 of 12

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Which unexpected findings require further evaluation if noted during the general survey of a patient’s gait?

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Tremor

The presence of a tremor is an abnormal finding, likely indicating a neurologic condition. This general survey finding requires further evaluation.

Smooth

Walking and mobility should be smooth. This general survey finding does not require further evaluation.

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Shuffling

Shuffling gait is an abnormal finding, likely indicating a neurologic condition. This general survey finding requires further evaluation.

Balanced

Walking and mobility should be well balanced. This general survey finding does not require further evaluation.

Symmetric

Gait and steps should be even, or symmetric. This general survey finding does not require further evaluation.

Question 6 of 12

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During the general survey, which body structure findings would the nurse document?

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Stature

Stature, appropriateness of height for age and genetic heritage, is a feature of the body structure component.

Correct

Symmetry

Symmetry, which occurs when body parts are proportionate and equal bilaterally, is a characteristic used to describe body structure.

Skin color

Skin color is a variable related to physical appearance, not body structure.

Correct

Fat distribution

Nutrition, fat distribution, and relationship of weight/height/build, are findings related to body structure.

Facial features

Facial features are a characteristic of physical appearance, not body structure.

Question 7 of 12

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Which situation describes an appropriate time for the nurse to obtain a focused health history instead of a full health history?

Patient admission 5 years ago

A full health history is required for patients not seen for several years because their health status could have changed significantly during that time.

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Clinic visit following hospitalization

A clinic visit following hospitalization requires only a focused health history to update the nurse and health care provider. The full history would have been conducted earlier.

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Emergency department visit for chest pain

An emergency department visit generally requires only a focused health history to enable the nurse to focus on the problem for which the patient presented for care.

New patient on hospital admission

A full health history is required when a new patient is admitted to the hospital to understand the patient’s current needs and past health status.

Initial visit to a new health care provider

Initial visits to new health care providers require extra time because they require full health histories. The nurse needs to understand the new patient’s health history before performing the physical examination.

Question 8 of 12 – Chapter 16, Nursing Assessment Patient Interview Answers

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Which potential statement would the nurse document in a patient’s focused health history?

Is a Hispanic male appearing to be the stated age
Statements documented about the patient’s age, gender, and cultural background are part of the full health history, not the focused health history.

Reports allergies to shellfish and peanuts
Statements about allergies and sensitivities are part of the full health history, not the focused health history.

Has a family history of type 2 diabetes mellitus
Statements documented about family histories of diseases, such as type 2 diabetes mellitus, are part of the full health history, not the focused health history. Chapter 16, Nursing Assessment Patient Interview Answers

Correct

Denies chest pain or rapid heart rate over the past week
Statements documented about specific focus areas, such as chest pain, rapid heart rate, or other specific conditions, are documented in a focused health history.

Question 9 of 12

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Which areas would the nurse address when obtaining a full health history?

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Primary language

Biographic data collected as part of the health history is comprehensive in scope and addresses a wide range of patient data, such as age/birth date, gender, occupation, and primary language.

Correct

Past health events

The nurse collects prior medical history information about past health events, childhood illnesses, accidents/injuries, and serious or chronic illnesses.

Data from past pulmonary function tests

Respiratory history, including data from past pulmonary tests, is a focused history restricted in scope, with a limited range of data collected.

Correct

Patient statement describing reason for visit

The nurse incudes the reason for seeking care in the health history. This is a brief, spontaneous statement in the person’s own words describing the reason for the visit.

Correct

Comparison of current medication with previous medication

The health history includes medication reconciliation, which is a comparison of a list of current medications with previous medications to reduce errors and promote patient safety.

Question 10 of 12

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During the review of systems, which action would the nurse take when a patient voices heart disease concerns secondary to a strong family history?

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Ask a focused question about the patient’s concerns.
Because the patient voiced concern about a health issue, the nurse should proceed to ask focused questions about that concern.

Investigate the patient’s desire for diagnostic testing.
Nurses cannot make decisions about diagnostic testing, but they can relay such information to the health care provider. This is not the next action the nurse should take.

Gather more information about the patient’s family history.
Gathering more information about family history takes the focus away from the patient and the review of systems.

Continue reviewing systems to identify additional health concerns.
Identifying other health concerns is important, but this is not the next action the nurse should take.

Question 11 of 12

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Which characteristics describe documentation of findings from a patient’s review of systems?

Contains objective data

Documentation of the review of systems includes only patient statements or subjective data—factors that the person says were or were not present.

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Is concise and accurate

The nurse should document the review of systems in the patient’s health care concisely and accurately.

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Is performed according to agency policy

The nurse should document the review of systems according to agency policy.

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Includes health-promotion activities

The nurse addresses health promotion throughout the review of systems.

Is completed after the physical examination

Prompt and complete documentation supports improved communication among health care team members. The physical examination occurs after the review of systems, so the nurse should document the review of systems before the physical examination. This will also prevent potential errors if the nurse confuses findings from the review of systems with those of the physical examination.

Question 12 of 12 – Chapter 16, Nursing Assessment Patient Interview Answers

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Which component would the nurse include when documenting findings from the review of systems?

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Patient statements
Documentation of the review of systems includes only patient statements or subjective data—factors that the person says were or were not present.

Physical appearance
Physical appearance is a component of the general survey.

Objective patient cues
The review of systems includes only subjective data, so objective patient cues would not be included.

Physical examination findings
Physical examination findings are not a component of the review of systems.

Chapter 16, Nursing Assessment Patient Interview Answers