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When recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
- A. Patient denies usual childhood illnesses.
- B. Patient states he was a 'very healthy' child.
- C. Patient states sister had measles, but he didn't.
- D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
Correct Answer: D
Rationale: Choice D is the most accurate note by the nurse as it lists specific childhood illnesses commonly experienced by children. By documenting that the patient denies having had these specific illnesses, the healthcare provider establishes a clear medical history record regarding these common childhood illnesses. This detailed documentation is essential for providing comprehensive care and evaluating potential risks or complications associated with these illnesses in the future. Choices A, B, and C are not as accurate as they do not provide a comprehensive list of common childhood illnesses that are routinely evaluated by healthcare providers. Choice A is too vague, Choice B focuses on the patient's perception of their health rather than specific illnesses, and Choice C only mentions measles, lacking the breadth of information provided in Choice D.
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During an interview, the nurse states, 'You mentioned shortness of breath. Tell me more about that.' Which verbal skill is used with this statement?
- A. Reflection
- B. Facilitation
- C. Direct question
- D. Open-ended question
Correct Answer: D
Rationale: The nurse's statement, 'Tell me more about that,' is an example of an open-ended question. Open-ended questions encourage the interviewee to provide detailed information and expand on their responses. This type of question is useful for gathering narrative information and allows the interviewee to express themselves freely. Reflection involves restating or paraphrasing the client's words, facilitation encourages the client to say more, and direct questions typically elicit specific, close-ended responses, unlike open-ended questions.
When planning a cultural assessment, which component should be included?
- A. Family history
- B. Chief complaint
- C. Medical history
- D. Health-related beliefs
Correct Answer: D
Rationale: When planning a cultural assessment, the nurse should include the component of health-related beliefs. Understanding a person's cultural background and beliefs about health and wellness is crucial for providing culturally competent care. Health-related beliefs can impact a person's attitudes towards illness, treatment preferences, and adherence to medical recommendations. Therefore, assessing health-related beliefs is essential for delivering effective and respectful healthcare services. Choices A, B, and C are important components of a comprehensive patient assessment but are not specific to cultural considerations. While family history, chief complaint, and medical history are pertinent to understanding a patient's health status, health-related beliefs focus specifically on the cultural aspect that influences an individual's health perceptions and behaviors.
During an interview, the interviewer is using open-ended questions. Which of the following statements are true regarding open-ended questions? Select all that apply.
- A. They elicit cold facts.
- B. They allow for self-expression.
- C. They build and enhance deviation from topic
- D. They leave interactions neutral.
Correct Answer: B
Rationale: Open-ended questions are designed to encourage the interviewee to express themselves freely, leading to more detailed and insightful responses. These questions help build rapport by showing interest in the interviewee's thoughts and feelings. By allowing for self-expression, open-ended questions facilitate a deeper and more meaningful conversation, making them a valuable tool in conducting interviews. Choice A is incorrect because open-ended questions aim to gather detailed and subjective information, not just cold facts. Choice D is incorrect as open-ended questions often lead to more engaging interactions rather than leaving them neutral.
What would be an appropriate nursing response when a mother reports that her 16-month-old toddler has an earache?
- A. Maybe the toddler is just teething.
- B. I will check her ear for an ear infection.
- C. Are you sure the toddler is really in pain?
- D. Please describe what the toddler is doing to indicate she is in pain.
Correct Answer: B
Rationale: The appropriate nursing response would be to assess the toddler's ear to determine if there is indeed an ear infection causing the earache. It is crucial to provide timely and suitable care for the child's pain and discomfort. Checking for an ear infection is a necessary step in evaluating the source of the toddler's earache. Choice A is incorrect as it assumes the earache is due to teething without proper assessment. Choice C questions the mother's report rather than focusing on the child's condition. Choice D is not as direct and focused as directly examining the ear for a possible infection.
When a nurse is performing a health interview on a patient with a language barrier and no interpreter is available, which of the following is the best example of an appropriate question for the nurse to ask?
- A. Do you take medicine?
- B. Do you sterilize the bottles?
- C. Do you have nausea and vomiting?
- D. You have been taking your medicine, haven't you?
Correct Answer: A
Rationale: The best example of an appropriate question for the nurse to ask in this situation is 'Do you take medicine?' This question is clear, simple, and focused on one topic at a time, which is essential when there is a language barrier and no interpreter available. It follows the recommendation to use simple words, avoid medical jargon, contractions, and pronouns in such situations. Choices B, C, and D involve more complex language, unrelated topics, or assumptions about the patient's actions, making them less suitable for effective communication in this context.