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A nurse is collecting information from Mr. Koeppe, a patient with dementia. The patients daughter, Sarah, accompanies the patient. Which of the following statements by the nurse would recognize the patients value as an individual?
- A. Sarah, can you tell me how long your father has been this way?
- B. Sarah, I have to go and read your fathers old charts before we talk.
- C. Mr. Koeppe, tell me what you do to take care of yourself.
- D. Mr. Koeppe, I know you cant answer my questions, but its okay.
Correct Answer: C
Rationale: Addressing the patient directly respects their individuality and encourages their participation.
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Which of the following examples of patient data needs to be validated? Select all that apply.
- A. A patient has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly patient explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a patient with a respiratory infection documents fever and chills.
- D. A patient in a nursing home states that she is unable to eat the food being served.
- E. A pregnant patient is experiencing contractions that are 2 minutes apart.
- F. Following a MVA, the teenage driver with alcohol on his breath states that he was not drinking.
Correct Answer: A,B,F
Rationale: Data requiring validation includes inconsistencies (A), potential abuse indicators (B), and contradictory statements (F).
A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply.
- A. carrying out a physicians order to intubate a patient
- B. teaching a novice nurse the principles of triage
- C. using the nursing process to diagnose a blocked airway
- D. interviewing a patient suspected of being a victim of abuse privately
- E. checking the data supplied by a patient with dementia with the family
- F. teaching a diabetic patient about the importance of proper foot care
Correct Answer: C,D,E
Rationale: Critical thinking in assessment includes diagnosing conditions (C), conducting private interviews to gather sensitive data (D), and validating information with reliable sources (E).
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.
The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
- A. to gather data about a specific and current health problem
- B. to identify life-threatening problems that require immediate attention
- C. to compare and contrast current health status to baseline data
- D. to establish a database to identify problems and strengths
Correct Answer: D
Rationale: An initial assessment creates a comprehensive database to identify patient problems and strengths for planning care.
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.