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A nurse is collecting data from a home care patient. In addition to information about the patients health status, what is another observation the nurse should make?
- A. number of rooms in the house
- B. safety of the immediate environment
- C. frequency of home visits to be made
- D. friendliness of the patient and family
Correct Answer: B
Rationale: Assessing environmental safety is critical in home care to prevent risks like falls.
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Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?
- A. The nursing diagnosis confirms the medical diagnosis.
- B. The nursing diagnosis duplicates the medical diagnosis.
- C. There is no relationship between nursing and medical diagnoses.
- D. The nursing diagnosis is based on patient response to the medical diagnosis.
Correct Answer: D
Rationale: Nursing diagnoses address the patient's response to the medical condition, distinct from the medical diagnosis itself.
Of the following data, what type would be collected during a physical assessment?
- A. color, moisture, and temperature of the skin
- B. type, amount, and duration of pain
- C. foods eaten that cause nausea
- D. specific allergies resulting in itching
Correct Answer: A
Rationale: Physical assessment involves observable data like skin characteristics.
Which of the following are characteristics of intimate distance or zone in communication? Select all that apply.
- A. 0 to 18 inches
- B. 18 inches to 4 feet
- C. 4 to 12 feet
- D. involves comforting touch
- E. involves visual distortion
- F. includes professional distance
- G. includes social distance
Correct Answer: A,D,E
Rationale: Intimate distance (0-18 inches) involves close contact, comforting touch, and potential visual distortion due to proximity.
A student takes an adult patients pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?
- A. Record the pulse rate on the appropriate vital signs sheet in the chart.
- B. Ask the instructor or a staff nurse to take the pulse.
- C. Discuss this finding during postconference with other students.
- D. Wait 4 hours and take the patients pulse again.
Correct Answer: B
Rationale: An abnormal finding like a pulse of 20 beats/min requires immediate verification by a qualified professional.
What is the primary purpose of validation as a part of assessment?
- A. to identify data to be validated
- B. to establish an effective nursepatient communication
- C. to maintain effective relationships with coworkers
- D. to plan appropriate nursing care
Correct Answer: D
Rationale: Validation ensures accurate data for effective care planning.