Physical Examination and Health Assessment 8th Edition Test Bank

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Chapter 01: Evidence-Based AssessmentChapter 01: Evidence-Based AssessmentJarvis: Physical Examination & Health Assessment, 7th EditionMULTIPLE CHOICE1.After completing an initial assessment of a patient, the nurse has charted that his respirationsare eupneic and his pulse is 58 beats per minute. These types of data would be:a.Objective.b.Reflective.c.Subjective.d.Introspective.ANS: AObjective data are what the health professional observes by inspecting, percussing, palpating,and auscultating during the physical examination. Subjective data is what the personsaysabouthim or herself during history taking. The termsreflectiveandintrospectiveare not used todescribe data.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2MSC: Client Needs: Safe and Effective Care Environment: Management of Care2.A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types ofdata would be:a.Objective.b.Reflective.c.Subjective.d.Introspective.ANS: CSubjective data are what the person says about him or herself during history taking. Objectivedata are what the health professional observes by inspecting, percussing, palpating, and

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auscultating during the physical examination. The termsreflectiveandintrospectiveare not usedto describe data.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2MSC: Client Needs: Safe and Effective Care Environment: Management of Care3.The patient’s record, laboratory studies, objective data, and subjective data combine to formthe:a.Data base.b.Admitting data.c.Financial statement.d.Discharge summary.ANS: ATogether with the patient’s record and laboratory studies, the objective and subjective data formthe data base. The other items are not part of the patient’s record, laboratory studies, or data.DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2MSC: Client Needs: Safe and Effective Care Environment: Management of Care4.When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. Thenurse’s next action should be to:a.Immediately notify the patient’s physician.b.Document the sound exactly as it was heard.c.Validate the data by asking a coworker to listen to the breath sounds.d.Assess again in 20 minutes to note whether the sound is still present.ANS: CWhen unsure of a sound heard while listening to a patient’s breath sounds, the nurse validates thedata to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expertto listen.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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5.The nurse is conducting a class for new graduate nurses. During the teaching session, the nurseshould keep in mind that novice nurses, without a background of skills and experience fromwhich to draw, are more likely to make their decisions using:a.Intuition.b.A set of rules.c.Articles in journals.d.Advice from supervisors.ANS: BNovice nurses operate from a set of defined, structured rules. The expert practitioner usesintuitive links.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3MSC: Client Needs: General6.Expert nurses learn to attend to a pattern of assessment data and act without consciouslylabeling it. These responses are referred to as:a.Intuition.b.The nursing process.c.Clinical knowledge.d.Diagnostic reasoning.ANS: AIntuition is characterized by pattern recognition—expert nurses learn to attend to a pattern ofassessment data and act without consciously labeling it. The other options are not correct.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4MSC: Client Needs: General7.The nurse is reviewing information about evidence-based practice (EBP). Which statementbest reflects EBP?a.EBP relies on tradition for support of best practices.b.EBP is simply the use of best practice techniques for the treatment of patients.

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c.EBP emphasizes the use of best evidence with the clinician’s experience.d.The patient’s own preferences are not important with EBP.ANS: CEBP is a systematic approach to practice that emphasizes the use of best evidence in combinationwith the clinician’s experience, as well as patient preferences and values, when making decisionsabout care and treatment. EBP is more than simply using the best practice techniques to treatpatients, and questioning tradition is important when no compelling and supportive researchevidence exists.DIF: Cognitive Level: Applying (Application) REF: p. 5MSC: Client Needs: Safe and Effective Care Environment: Management of Care8.The nurse is conducting a class on priority setting for a group of new graduate nurses. Which isan example of a first-level priority problem?a.Patient with postoperative painb.Newly diagnosed patient with diabetes who needs diabetic teachingc.Individual with a small laceration on the sole of the footd.Individual with shortness of breath and respiratory distressANS: DFirst-level priority problems are those that are emergent, life threatening, and immediate (e.g.,establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vitalsigns) (see Table 1-1).DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4MSC: Client Needs: Safe and Effective Care Environment: Management of Care9.When considering priority setting of problems, the nurse keeps in mind that second-levelpriority problems include which of these aspects?a.Low self-esteemb.Lack of knowledgec.Abnormal laboratory valuesd.Severely abnormal vital signs

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ANS: CSecond-level priority problems are those that require prompt intervention to forestall furtherdeterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safetyor security) (see Table 1-1).DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4MSC: Client Needs: Safe and Effective Care Environment: Management of Care10.Which critical thinking skill helps the nurse see relationships among the data?a.Validationb.Clustering related cuesc.Identifying gaps in datad.Distinguishing relevant from irrelevantANS: BClustering related cues helps the nurse see relationships among the data.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2MSC: Client Needs: Safe and Effective Care Environment: Management of Care11.The nurse knows that developing appropriate nursing interventions for a patient relies on theappropriateness of the __________ diagnosis.a.Nursingb.Medicalc.Admissiond.CollaborativeANS: AAn accurate nursing diagnosis provides the basis for the selection of nursing interventions toachieve outcomes for which the nurse is accountable. The other items do not contribute to thedevelopment of appropriate nursing interventions.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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12.The nursing process is a sequential method of problem solving that nurses use and includeswhich steps?a.Assessment, treatment, planning, evaluation, discharge, and follow-upb.Admission, assessment, diagnosis, treatment, and discharge planningc.Admission, diagnosis, treatment, evaluation, and discharge planningd.Assessment, diagnosis, outcome identification, planning, implementation, and evaluationANS: DThe nursing process is a method of problem solving that includes assessment, diagnosis,outcome identification, planning, implementation, and evaluation.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3MSC: Client Needs: Safe and Effective Care Environment: Management of Care13.A newly admitted patient is in acute pain, has not been sleeping well lately, and is havingdifficulty breathing. How should the nurse prioritize these problems?a.Breathing, pain, and sleepb.Breathing, sleep, and painc.Sleep, breathing, and paind.Sleep, pain, and breathingANS: AFirst-level priority problems are immediate priorities, remembering the ABCs (airway, breathing,and circulation), followed by second-level problems, and then third-level problems.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4MSC: Client Needs: Safe and Effective Care Environment: Management of Care14.Which of these would be formulated by a nurse using diagnostic reasoning?a.Nursing diagnosisb.Medical diagnosisc.Diagnostic hypothesis

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d.Diagnostic assessmentANS: CDiagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing processcalls for a nursing diagnosis.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2MSC: Client Needs: General15.Barriers to incorporating EBP include:a.Nurses’ lack of research skills in evaluating the quality of research studies.b.Lack of significant research studies.c.Insufficient clinical skills of nurses.d.Inadequate physical assessment skills.ANS: AAs individuals, nurses lack research skills in evaluating the quality of research studies, areisolated from other colleagues who are knowledgeable in research, and often lack the time tovisit the library to read research. The other responses are not considered barriers.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6MSC: Client Needs: General16.What step of the nursing process includes data collection by health history, physicalexamination, and interview?a.Planningb.Diagnosisc.Evaluationd.AssessmentANS: DData collection, including performing the health history, physical examination, and interview, isthe assessment step of the nursing process (see Figure 1-2).

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DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2MSC: Client Needs: General17.During a staff meeting, nurses discuss the problems with accessing research studies toincorporate evidence-based clinical decision making into their practice. Which suggestion by thenurse manager would best help these problems?a.Form a committee to conduct research studies.b.Post published research studies on the unit’s bulletin boards.c.Encourage the nurses to visit the library to review studies.d.Teach the nurses how to conduct electronic searches for research studies.ANS: DFacilitating support for EBP would include teaching the nurses how to conduct electronicsearches; time to visit the library may not be available for many nurses. Actually conductingresearch studies may be helpful in the long-run but not an immediate solution to reviewingexisting research.DIF: Cognitive Level: Applying (Application) REF: p. 6MSC: Client Needs: Safe and Effective Care Environment: Management of Care18.When reviewing the concepts of health, the nurse recalls that the components of holistichealth include which of these?a.Disease originates from the external environment.b.The individual human is a closed system.c.Nurses are responsible for a patient’s health state.d.Holistic health views the mind, body, and spirit as interdependent.ANS: DConsideration of the whole person is the essence of holistic health, which views the mind, body,and spirit as interdependent. The basis of disease originates from both the external environmentand from within the person. Both the individual human and the external environment are opensystems, continually changing and adapting, and each person is responsible for his or her ownpersonal health state.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7

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MSC: Client Needs: Safe and Effective Care Environment: Management of Care19.The nurse recognizes that the concept of prevention in describing health is essential because:a.Disease can be prevented by treating the external environment.b.The majority of deaths among Americans under age 65 years are not preventable.c.Prevention places the emphasis on the link between health and personal behavior.d.The means to prevention is through treatment provided by primary health care practitioners.ANS: CA natural progression to prevention rounds out the present concept of health. Guidelines toprevention place the emphasis on the link between health and personal behavior.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7MSC: Client Needs: General20.The nurse is performing a physical assessment on a newly admitted patient. An example ofobjective information obtained during the physical assessment includes the:a.Patient’s history of allergies.b.Patient’s use of medications at home.c.Last menstrual period 1 month ago.d.25 cm scar on the right lower forearm.ANS: DObjective data are the patient’s record, laboratory studies, and condition that the healthprofessional observes by inspecting, percussing, palpating, and auscultating during the physicalexamination. The other responses reflect subjective data.DIF: Cognitive Level: Applying (Application) REF: p. 2MSC: Client Needs: Safe and Effective Care Environment: Management of Care21.A visiting nurse is making an initial home visit for a patient who has many chronic medicalproblems. Which type of data base is most appropriate to collect in this setting?a.A follow-up data base to evaluate changes at appropriate intervals

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b.An episodic data base because of the continuing, complex medical problems of this patientc.A complete health data base because of the nurse’s primary responsibility for monitoringthe patient’s healthd.An emergency data base because of the need to collect information and make accuratediagnoses rapidlyANS: CThe complete data base is collected in a primary care setting, such as a pediatric or familypractice clinic, independent or group private practice, college health service, women’s healthcare agency, visiting nurse agency, or community health agency. In these settings, the nurse isthe first health professional to see the patient and has the primary responsibility for monitoringthe person’s health care.DIF: Cognitive Level: Applying (Application) REF: p. 6MSC: Client Needs: Safe and Effective Care Environment: Management of Care22.Which situation is most appropriate during which the nurse performs a focused or problem-centered history?a.Patient is admitted to a long-term care facility.b.Patient has a sudden and severe shortness of breath.c.Patient is admitted to the hospital for surgery the following day.d.Patient in an outpatient clinic has cold and influenza-like symptoms.ANS: DIn a focused or problem-centered data base, the nurse collects a “mini” data base, which issmaller in scope than the completed data base. This mini data base primarily concerns oneproblem, one cue complex, or one body system.DIF: Cognitive Level: Applying (Application) REF: p. 7MSC: Client Needs: Safe and Effective Care Environment: Management of Care23.A patient is at the clinic to have her blood pressure checked. She has been coming to theclinic weekly since she changed medications 2 months ago. The nurse should:a.Collect a follow-up data base and then check her blood pressure.b.Ask her to read her health record and indicate any changes since her last visit.

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c.Check only her blood pressure because her complete health history was documented 2months ago.d.Obtain a complete health history before checking her blood pressure because much of herhistory information may have changed.ANS: AA follow-up data base is used in all settings to follow up short-term or chronic health problems.The other responses are not appropriate for the situation.DIF: Cognitive Level: Applying (Application) REF: p. 7MSC: Client Needs: Safe and Effective Care Environment: Management of Care24.A patient is brought by ambulance to the emergency department with multiple traumasreceived in an automobile accident. He is alert and cooperative, but his injuries are quite severe.How would the nurse proceed with data collection?a.Collect history information first, then perform the physical examination and institute life-saving measures.b.Simultaneously ask history questions while performing the examination and initiating life-saving measures.c.Collect all information on the history form, including social support patterns, strengths, andcoping patterns.d.Perform life-saving measures and delay asking any history questions until the patient istransferred to the intensive care unit.ANS: BThe emergency data base calls for a rapid collection of the data base, often concurrentlycompiled with life-saving measures. The other responses are not appropriate for the situation.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 7MSC: Client Needs: Safe and Effective Care Environment: Management of Care25.A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination.The nurse knows that including cultural information in his health assessment is important to:a.Identify the cause of his illness.b.Make accurate disease diagnoses.

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c.Provide cultural health rights for the individual.d.Provide culturally sensitive and appropriate care.ANS: DThe inclusion of cultural considerations in the health assessment is of paramount importance togathering data that are accurate and meaningful and to intervening with culturally sensitive andappropriate care.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 8MSC: Client Needs: Psychosocial Integrity26.In the health promotion model, the focus of the health professional includes:a.Changing the patient’s perceptions of disease.b.Identifying biomedical model interventions.c.Identifying negative health acts of the consumer.d.Helping the consumer choose a healthier lifestyle.ANS: DIn the health promotion model, the focus of the health professional is on helping the consumerchoose a healthier lifestyle.DIF: Cognitive Level: Remembering (Knowledge) REF: p. 8MSC: Client Needs: Health Promotion and Maintenance27.The nurse has implemented several planned interventions to address the nursing diagnosis ofacute pain. Which would be the next appropriate action?a.Establish priorities.b.Identify expected outcomes.c.Evaluate the individual’s condition, and compare actual outcomes with expected outcomes.d.Interpret data, and then identify clusters of cues and make inferences.ANS: C

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Evaluation is the next step after the implementation phase of the nursing process. During thisstep, the nurse evaluates the individual’s condition and compares the actual outcomes withexpected outcomes (See Figure 1-2).DIF: Cognitive Level: Applying (Application) REF: p. 3MSC: Client Needs: Safe and Effective Care Environment: Management of Care28.Which statementbestdescribes a proficient nurse? A proficient nurse is one who:a.Has little experience with a specified population and uses rules to guide performance.b.Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution.c.Sees actions in the context of daily plans for patients.d.Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient.ANS: DThe proficient nurse, with more time and experience than the novice nurse, is able to understanda patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see howtoday’s nursing actions can apply to the point the nurse wants the patient to reach at a futuretime.DIF: Cognitive Level: Applying (Application) REF: p. 3MSC: Client Needs: GeneralMULTIPLE RESPONSE1.The nurse is reviewing data collected after an assessment. Of the data listed below, whichwould be considered related cues that would be clustered together during data analysis?Selectall that apply.a.Inspiratory wheezes noted in left lower lobesb.Hypoactive bowel soundsc.Nonproductive coughd.Edema, +2, noted on left hande.Patient reports dyspnea upon exertionf.Rate of respirations 16 breaths per minute

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ANS: A, C, E, FClustering related cues help the nurse recognize relationships among the data. The cues related tothe patient’s respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate andrhythm) are all related. Cues related to bowels and peripheral edema are not related to therespiratory cues.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4MSC: Client Needs: Safe and Effective Care Environment: Management of CareMATCHINGPut the following patient situations in order according to the level of priority.a.A patient newly diagnosed with type 2 diabetes mellitus does not know how to check hisown blood glucose levels with a glucometer.b.A teenager who was stung by a bee during a soccer match is having trouble breathing.c.An older adult with a urinary tract infection is also showing signs of confusion andagitation.1.a = First-level priority problem2.b = Second-level priority problem3.c = Third-level priority problem1. ANS: B DIF: Cognitive Level: Analyzing (Analysis)REF: p. 4MSC: Client Needs: Safe and Effective Care Environment: Management of CareNOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the “airway,breathing, circulation” priorities). Second-level priority problems are next in urgency, but not life-threatening.Third-level priorities (e.g., patient education) are important to a patient’s health but can be addressed after moreurgent health problems are addressed (see Table 1-1).2. ANS: C DIF: Cognitive Level: Analyzing (Analysis)REF: p. 4MSC: Client Needs: Safe and Effective Care Environment: Management of CareNOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the “airway,breathing, circulation” priorities). Second-level priority problems are next in urgency, but not life-threatening.

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Third-level priorities (e.g., patient education) are important to a patient’s health but can be addressed after moreurgent health problems are addressed (see Table 1-1).3. ANS: A DIF: Cognitive Level: Analyzing (Analysis)REF: p. 4MSC: Client Needs: Safe and Effective Care Environment: Management of CareNOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the “airway,breathing, circulation” priorities). Second-level priority problems are next in urgency, but not life-threatening.Third-level priorities (e.g., patient education) are important to a patient’s health but can be addressed after moreurgent health problems are addressed (see Table 1-1).Chapter 02: Cultural CompetenceChapter 02: Cultural CompetenceJarvis: Physical Examination & Health Assessment, 7th EditionMULTIPLE CHOICE1.The nurse is reviewing the development of culture. Which statement iscorrectregarding thedevelopment of one’s culture? Culture is:a.Genetically determined on the basis of racial background.b.Learned through language acquisition and socialization.c.A nonspecific phenomenon and is adaptive but unnecessary.d.Biologically determined on the basis of physical characteristics.ANS: BCulture is learned from birth through language acquisition and socialization. It is not biologicallyor genetically determined and is learned by the individual.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 14MSC: Client Needs: Psychosocial Integrity2.During a class on the aspects of culture, the nurse shares that culture has four basiccharacteristics. Which statement correctly reflects one of these characteristics?a.Cultures are static and unchanging, despite changes around them.

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b.Cultures are never specific, which makes them hard to identify.c.Culture is most clearly reflected in a person’s language and behavior.d.Culture adapts to specific environmental factors and available natural resources.ANS: DCulture has four basic characteristics. Culture adapts to specific conditions related toenvironmental and technical factors and to the availability of natural resources, and it is dynamicand ever changing. Culture is learned from birth through the process of language acquisition andsocialization, but it is not most clearly reflected in one’s language and behavior.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 14MSC: Client Needs: Psychosocial Integrity3.During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating“the specific and distinct knowledge, beliefs, skills, and customs acquired by members of asociety” reflects which term?a.Moresb.Normsc.Cultured.Social learningANS: CThe culture that develops in any given society is always specific and distinctive, encompassingall of the knowledge, beliefs, customs, and skills acquired by members of the society. The otherterms do not fit the given definition.DIF: Cognitive Level: Remembering (Knowledge) REF: p. 14MSC: Client Needs: Psychosocial Integrity4.When discussing the use of the termsubculture, the nurse recognizes that it is best describedas:a.Fitting as many people into the majority culture as possible.b.Defining small groups of people who do not want to be identified with the larger culture.c.Singling out groups of people who suffer differential and unequal treatment as a result of

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cultural variations.d.Identifying fairly large groups of people with shared characteristics that are not common toall members of a culture.ANS: DWithin cultures, groups of people share different beliefs, values, and attitudes. Differences occurbecause of ethnicity, religion, education, occupation, age, and gender. When such groupsfunction within a large culture, they are referred to assubcultural groups.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 14MSC: Client Needs: Psychosocial Integrity5.When reviewing the demographics of ethnic groups in the United States, the nurse recalls thatthe largest and fastest growing population is:a.Hispanic.b.Black.c.Asian.d.American Indian.ANS: AHispanics are the largest and fastest growing population in the United States, followed byAsians, Blacks, American Indians and Alaska natives, and other groups.DIF: Cognitive Level: Remembering (Knowledge) REF: p. 11MSC: Client Needs: General6.During an assessment, the nurse notices that a patient is handling a small charm that is tied to aleather strip around his neck. Which action by the nurse is appropriate?a.Ask the patient about the item and its significance.b.Ask the patient to lock the item with other valuables in the hospital’s safe.c.Tell the patient that a family member should take valuables home.d.No action is necessary.ANS: A

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The nurse should inquire about the amulet’s meaning. Amulets, such as charms, are oftenconsidered an important means of protection from “evil spirits” by some cultures.DIF: Cognitive Level: Applying (Application) REF: p. 19MSC: Client Needs: Psychosocial Integrity7.The nurse manager is explaining culturally competent care during a staff meeting. Whichstatement accurately describes the concept of culturally competent care? “The caregiver:a.Is able to speak the patient’s native language.”b.Possesses some basic knowledge of the patient’s cultural background.”c.Applies the proper background knowledge of a patient’s cultural background to provide thebest possible health care.”d.Understands and attends to the total context of the patient’s situation.”ANS: DCulturally competent implies that the caregiver understands and attends to the total context of theindividual’s situation. This competency includes awareness of immigration status, stress factors,other social factors, and cultural similarities and differences. It does not require the caregiver tospeak the patient’s native language.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24MSC: Client Needs: Psychosocial Integrity8.The nurse recognizes that an example of a person who isheritage consistentwould be a:a.Woman who has adapted her clothing to the clothing style of her new country.b.Woman who follows the traditions that her mother followed regarding meals.c.Man who is not sure of his ancestor’s country of origin.d.Child who is not able to speak his parents’ native language.ANS: BSomeone who is heritage consistent lives a lifestyle that reflects his or her traditional heritage,not the norms and customs of the new country.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 24MSC: Client Needs: Psychosocial Integrity

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9.After a class on culture and ethnicity, the new graduate nurse reflects a correct understandingof the concept of ethnicity with which statement?a.“Ethnicity is dynamic and ever changing.”b.“Ethnicity is the belief in a higher power.”c.“Ethnicity pertains to a social group within the social system that claims shared values andtraditions.”d.“Ethnicity is learned from birth through the processes of language acquisition andsocialization.”ANS: CEthnicity pertains to a social group within the social system that claims to have variable traits,such as a common geographic origin, migratory status, religion, race, language, values,traditions, symbols, or food preferences.Cultureis dynamic, ever changing, and learned frombirth through the processes of language acquisition and socialization. Religion is the belief in ahigher power.DIF: Cognitive Level: Applying (Application) REF: p. 14MSC: Client Needs: Psychosocial Integrity10.The nurse is comparing the concepts of religion and spirituality. Which of the following is anappropriate component of one’s spirituality?a.Belief in and the worship of God or godsb.Attendance at a specific church or place of worshipc.Personal effort made to find purpose and meaning in lifed.Being closely tied to one’s ethnic backgroundANS: CSpirituality refers to each person’s unique life experiences and his or her personal effort to findpurpose and meaning in life. The other responses apply to religion.DIF: Cognitive Level: Applying (Application) REF: p. 15MSC: Client Needs: Psychosocial Integrity11.A woman who has lived in the United States for a year after moving from Europe has learnedto speak English and is almost finished with her college studies. She now dresses like her peers

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and says that her family in Europe would hardly recognize her. This nurse recognizes that thissituation illustrates which concept?a.Assimilationb.Heritage consistencyc.Biculturalismd.AcculturationANS: AAssimilation is the process by which a person develops a new cultural identity and becomes likemembers of the dominant culture. This concept does not reflect heritage consistency.Biculturalism is a dual pattern of identification; acculturation is the process of adapting to andacquiring another culture.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 15MSC: Client Needs: Psychosocial Integrity12.The nurse is conducting a heritage assessment. Which question is most appropriate for thisassessment?a.“What is your religion?”b.“Do you mostly participate in the religious traditions of your family?”c.“Do you smoke?”d.“Do you have a history of heart disease?”ANS: BAsking questions about participation in the religious traditions of family enables the nurse toassess a person’s heritage. Simply asking about one’s religion, smoking history, or health historydoes not reflect heritage.DIF: Cognitive Level: Applying (Application) REF: p. 24MSC: Client Needs: Psychosocial Integrity13.In the majority culture of America, coughing, sweating, and diarrhea are symptoms of anillness. For some individuals of Mexican-American origin, however, these symptoms are anormal part of living. The nurse recognizes that this difference is true, probably becauseMexican-Americans:

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a.Have less efficient immune systems and are often ill.b.Consider these symptoms part of normal living, not symptoms of ill health.c.Come from Mexico, and coughing is normal and healthy there.d.Are usually in a lower socioeconomic group and are more likely to be sick.ANS: BThe nurse needs to identify the meaning of health to the patient, remembering that concepts arederived, in part, from the way in which members of the cultural group define health.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 17MSC: Client Needs: Psychosocial Integrity14.The nurse is reviewing theories of illness. The germ theory, which states that microscopicorganisms such as bacteria and viruses are responsible for specific disease conditions, is a basicbelief of which theory of illness?a.Holisticb.Biomedicalc.Naturalisticd.MagicoreligiousANS: BAmong the biomedical explanations for disease is the germ theory, which states that microscopicorganisms such as bacteria and viruses are responsible for specific disease conditions. Thenaturalistic, or holistic, perspective holds that the forces of nature must be kept in naturalbalance. The magicoreligious perspective holds that supernatural forces dominate and causeillness or health.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18MSC: Client Needs: Psychosocial Integrity15.An Asian-American woman is experiencing diarrhea, which is believed to be “cold” or “yin.”The nurse expects that the woman is likely to try to treat it with:a.Foods that are “hot” or “yang.”b.Readings and Eastern medicine meditations.

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c.High doses of medicines believed to be “cold.”d.No treatment is tried because diarrhea is an expected part of life.ANS: AYin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foodsare eaten with a cold illness. The other explanations do not reflect the yin/yang theory.DIF: Cognitive Level: Applying (Application) REF: p. 18MSC: Client Needs: Psychosocial Integrity16.Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinesephilosophy of Tao. Which statement most accurately reflects “health” in an Asian with thisbelief?a.A person is able to work and produce.b.A person is happy, stable, and feels good.c.All aspects of the person are in perfect balance.d.A person is able to care for others and function socially.ANS: CMany Asians believe in the yin/yang theory, in which health is believed to exist when all aspectsof the person are in perfect balance. The other statements do not describe this theory.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 18MSC: Client Needs: Psychosocial Integrity17.Illness is considered part of life’s rhythmic course and is an outward sign of disharmonywithin. This statement most accurately reflects the views about illness from which theory?a.Naturalisticb.Biomedicalc.Reductionistd.MagicoreligiousANS: A

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The naturalistic perspective states that the laws of nature create imbalances, chaos, and disease.From the perspective of the Chinese, for example, illness is not considered an introducing agent;rather, illness is considered a part of life’s rhythmic course and an outward sign of disharmonywithin. The other options are not correct.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18MSC: Client Needs: Psychosocial Integrity18.An individual who takes the magicoreligious perspective of illness and disease is likely tobelieve that his or her illness was caused by:a.Germs and viruses.b.Supernatural forces.c.Eating imbalanced foods.d.An imbalance within his or her spiritual nature.ANS: BThe basic premise of the magicoreligious perspective is that the world is seen as an arena inwhich supernatural forces dominate. The fate of the world and those in it depends on the actionsof supernatural forces for good or evil. The other answers do not reflect the magicoreligiousperspective.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18MSC: Client Needs: Psychosocial Integrity19.If an American Indian woman has come to the clinic to seek help with regulating her diabetes,then the nurse can expect that she:a.Will comply with the treatment prescribed.b.Has obviously given up her belief in naturalistic causes of disease.c.May also be seeking the assistance of a shaman or medicine man.d.Will need extra help in dealing with her illness and may be experiencing a crisis of faith.ANS: CWhen self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems,to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from abiomedical or scientific health care provider, patients may also seek help from folk or religioushealers.

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DIF: Cognitive Level: Analyzing (Analysis) REF: p. 19MSC: Client Needs: Psychosocial Integrity20.An older Mexican-American woman with traditional beliefs has been admitted to an inpatientcare unit. A culturally sensitive nurse would:a.Contact the hospital administrator about the best course of action.b.Automatically get a curandero for her, because requesting one herself is not culturallyappropriate.c.Further assess the patient’s cultural beliefs and offer the patient assistance in contacting acurandero or priest if she desires.d.Ask the family what they would like to do because Mexican-Americans traditionally givecontrol of decision making to their families.ANS: CIn addition to seeking help from the biomedical or scientific health care provider, patients mayalso seek help from folk or religious healers. Some people, such as those of Mexican-Americanor American-Indian origins, may believe that the cure is incomplete unless the body, mind, andspirit are also healed (although the division of the person into parts is a Western concept).DIF: Cognitive Level: Analyzing (Analysis) REF: p. 19MSC: Client Needs: Psychosocial Integrity21.A 63-year-old Chinese-American man enters the hospital with complaints of chest pain,shortness of breath, and palpitations. Which statement most accurately reflects the nurse’s bestcourse of action?a.The nurse should focus on performing a full cardiac assessment.b.The nurse should focus on psychosomatic complaints because the patient has just learnedthat his wife has cancer.c.This patient is not in any danger at present; therefore, the nurse should send him home withinstructions to contact his physician.d.It is unclear what is happening with this patient; consequently, the nurse should perform anassessment in both the physical and the psychosocial realms.ANS: DWide cultural variations exist in the manner in which certain symptoms and disease conditionsare perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental

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experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because thecenter of emotion in the Chinese culture is the heart).DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 17-18MSC: Client Needs: Psychosocial Integrity22.Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which of thefollowing is atruestatement regarding pain?a.Nurses’ attitudes toward their patients’ pain are unrelated to their own experiences withpain.b.Nurses need to recognize that many cultures practice silent suffering as a response to pain.c.A nurse’s area of clinical practice will most likely determine his or her assessment of apatient’s pain.d.A nurse’s years of clinical experience and current position are strong indicators of his or herresponse to patient pain.ANS: BSilent suffering is a potential response to pain in many cultures. The nurse’s assessment of painneeds to be embedded in a cultural context. The other responses are not correct.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 22MSC: Client Needs: Psychosocial Integrity23.The nurse is reviewing concepts of cultural aspects of pain. Which statement istrueregardingpain?a.All patients will behave the same way when in pain.b.Just as patients vary in their perceptions of pain, so will they vary in their expressions ofpain.c.Cultural norms have very little to do with pain tolerance, because pain tolerance is alwaysbiologically determined.d.A patient’s expression of pain is largely dependent on the amount of tissue injury associatedwith the pain.ANS: B

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In addition to expecting variations in pain perception and tolerance, the nurse should expectvariations in the expression of pain. It is well known that individuals turn to their socialenvironment for validation and comparison. The other statements are incorrect.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 22MSC: Client Needs: Psychosocial Integrity24.During a class on religion and spirituality, the nurse is asked to define spirituality. Whichanswer is correct? “Spirituality:a.Is a personal search to discover a supreme being.”b.Is an organized system of beliefs concerning the cause, nature, and purpose of theuniverse.”c.Is a belief that each person exists forever in some form, such as a belief in reincarnation orthe afterlife.”d.Arises out of each person’s unique life experience and his or her personal effort to findpurpose in life.”ANS: DSpirituality arises out of each person’s unique life experience and his or her personal effort tofind purpose and meaning in life. The other definitions reflect the concept of religion.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 15MSC: Client Needs: Psychosocial Integrity25.The nurse recognizes that working with children with a different cultural perspective may beespecially difficult because:a.Children have spiritual needs that are influenced by their stages of development.b.Children have spiritual needs that are direct reflections of what is occurring in their homes.c.Religious beliefs rarely affect the parents’ perceptions of the illness.d.Parents are often the decision makers, and they have no knowledge of their children’sspiritual needs.ANS: AIllness during childhood may be an especially difficult clinical situation. Children, as well asadults, have spiritual needs that vary according to the child’s developmental level and thereligious climate that exists in the family. The other statements are not correct.

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DIF: Cognitive Level: Applying (Application) REF: p. 21MSC: Client Needs: Psychosocial Integrity26.A 30-year-old woman has recently moved to the United States with her husband. They areliving with the woman’s sister until they can get a home of their own. When company arrives tovisit with the woman’s sister, the woman feels suddenly shy and retreats to the back bedroom tohide until the company leaves. She explains that her reaction to guests is simply because shedoes not know how to speak “perfect English.” This woman could be experiencing:a.Culture shock.b.Cultural taboos.c.Cultural unfamiliarity.d.Culture disorientation.ANS: ACulture shockis a term used to describe the state of disorientation or inability to respond to thebehavior of a different cultural group because of its sudden strangeness, unfamiliarity, andincompatibility with the individual’s perceptions and expectations. The other terms are notcorrect.DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 21-22MSC: Client Needs: Psychosocial Integrity27.After a symptom is recognized, the first effort at treatment is often self-care. Which of thefollowing statements about self-care istrue? “Self-care is:a.Not recognized as valuable by most health care providers.”b.Usually ineffective and may delay more effective treatment.”c.Always less expensive than biomedical alternatives.”d.Influenced by the accessibility of over-the-counter medicines.”ANS: DAfter a symptom is identified, the first effort at treatment is often self-care. The availability ofover-the-counter medications, the relatively high literacy level of Americans, and the influenceof the mass media in communicating health-related information to the general population havecontributed to the high percentage of cases of self-treatment.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 19

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MSC: Client Needs: Psychosocial Integrity28.The nurse is reviewing the hot/cold theory of health and illness. Which statement bestdescribes the basic tenets of this theory?a.The causation of illness is based on supernatural forces that influence the humors of thebody.b.Herbs and medicines are classified on their physical characteristics of hot and cold and thehumors of the body.c.The four humors of the body consist of blood, yellow bile, spiritual connectedness, andsocial aspects of the individual.d.The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness torestore the balance of the humors of the body.ANS: DThe hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm,black bile, and yellow bile. These humors regulate the basic bodily functions, described in termsof temperature, dryness, and moisture. The treatment of disease consists of adding or subtractingcold, heat, dryness, or wetness to restore the balance of the humors. The other statements are notcorrect.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 18MSC: Client Needs: Psychosocial Integrity29.In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body.Which of these patient conditions is most consistent with a cold condition?a.Patient with diabetes and renal failureb.Teenager with an abscessed toothc.Child with symptoms of itching and a rashd.Older man with gastrointestinal discomfortANS: DIllnesses believed to be caused by cold entering the body include earache, chest cramps,gastrointestinal discomfort, rheumatism, and tuberculosis. Those illnesses believed to be causedby heat, or overheating, include sore throats, abscessed teeth, rashes, and kidney disorders.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 18

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MSC: Client Needs: Psychosocial Integrity30.When providing culturally competent care, nurses must incorporate cultural assessments intotheir health assessments. Which statement is most appropriate to use when initiating anassessment of cultural beliefs with an older American-Indian patient?a.“Are you of the Christian faith?”b.“Do you want to see a medicine man?”c.“How often do you seek help from medical providers?”d.“What cultural or spiritual beliefs are important to you?”ANS: DThe nurse needs to assess the cultural beliefs and practices of the patient. American Indians mayseek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing acultural assessment.DIF: Cognitive Level: Analyzing (Analysis) REF: p. 24MSC: Client Needs: Psychosocial Integrity31.During a class on cultural practices, the nurse hears the termcultural taboo. Which statementillustrates the concept of a cultural taboo?a.Believing that illness is a punishment of sinb.Trying prayer before seeking medical helpc.Refusing to accept blood products as part of treatmentd.Stating that a child’s birth defect is the result of the parents’ sinsANS: CCultural taboos are practices that are to be avoided, such as receiving blood products, eatingpork, and consuming caffeine. The other answers do not reflect cultural taboos.DIF: Cognitive Level: Applying (Application) REF: p. 21MSC: Client Needs: Psychosocial Integrity32.The nurse recognizes that categories such as ethnicity, gender, and religion illustrate theconcept of:

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a.Family.b.Cultures.c.Spirituality.d.Subcultures.ANS: DWithin cultures, groups of people share different beliefs, values, and attitudes. Differences occurbecause of ethnicity, religion, education, occupation, age, and gender. When such groupsfunction within a large culture, they are referred to assubcultural groups.DIF: Cognitive Level: Understanding (Comprehension) REF: p. 14MSC: Client Needs: Psychosocial Integrity33.The nurse is reviewing concepts related to one’s heritage and beliefs. The belief in divine orsuperhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universeis known as:a.Culture.b.Religion.c.Ethnicity.d.Spirituality.ANS: BReligion is defined as an organized system of beliefs concerning the cause, nature, and purposeof the universe, especially belief in or the worship of God or gods. Spirituality is born out of eachperson’s unique life experiences and his or her personal efforts to find purpose and meaning inlife. Ethnicity pertains to a social group within the social system that claims to possess variabletraits, such as a common geographic origin, religion, race, and others.DIF: Cognitive Level: Remembering (Knowledge) REF: p. 15MSC: Client Needs: Psychosocial Integrity34.When planning a cultural assessment, the nurse should include which component?a.Family historyb.Chief complaint

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