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A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
- A. My leg hurts so bad. I cant stand it.
- B. Appears anxious and frightened.
- C. I am so sick; I am about to throw up.
- D. Unable to palpate femoral pulse in left leg.
Correct Answer: D
Rationale: Objective data are measurable findings, such as the inability to palpate a pulse.
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What type of patient record data would the nurse find in the medical history and progress notes?
- A. findings of the physicians assessment and treatment
- B. results of laboratory and diagnostic studies
- C. nursing documentation and plan of care
- D. information from other members of the healthcare team
Correct Answer: A
Rationale: Medical history and progress notes contain physician assessments and treatment plans.
Who or what is the primary source of information for a nursing history?
- A. previous medical records
- B. other healthcare personnel
- C. the patient
- D. family members
Correct Answer: C
Rationale: The patient is the primary source for a nursing history, providing firsthand information about their health.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the residents ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
- A. to identify a life-threatening problem
- B. to establish a database for medical care
- C. to practice respiratory assessment skills
- D. to facilitate the residents ability to breathe
Correct Answer: A
Rationale: Assessing respiratory status in this scenario identifies a life-threatening issue requiring immediate intervention.
Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?
- A. Why didnt you go to the doctor when you began to have this pain?
- B. Are you feeling better now than you did during the night?
- C. Tell me more about what caused your pain.
- D. If I were you, I would not wait to get medical help next time.
Correct Answer: C
Rationale: Open-ended questions like 'Tell me more' encourage detailed patient responses.
A nurse who collected and organized data during a patient history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?
- A. The nurse should practice interviewing strategies.
- B. The nurse should modify data collection tool.
- C. The nurse should determine specific purpose of data collection.
- D. The nurse should review and practice communication techniques.
Correct Answer: A
Rationale: Practicing interviewing strategies improves data collection thoroughness.