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A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, I have been so constipated lately. How should the nurse respond?
- A. Do you have a family history of chest problems?
- B. Why dont you use a laxative every night?
- C. Do you take anything to help your constipation?
- D. Everyone who ages has bowel problems.
Correct Answer: C
Rationale: Asking about current management of the symptom encourages relevant information.
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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 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.
A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself?
- A. standing at the end of the bed
- B. standing at the side of the bed
- C. sitting at least 6 feet from the beside
- D. sitting at a 45-degree angle to the bed
Correct Answer: D
Rationale: Sitting at a 45-degree angle facilitates eye contact and communication with a bedridden patient.
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.
Of the following information collected during a nursing assessment, which are subjective data?
- A. vomiting, pulse 96
- B. respirations 22, blood pressure 130/80
- C. nausea, abdominal pain
- D. pale skin, thick toenails
Correct Answer: C
Rationale: Subjective data are symptoms reported by the patient, such as nausea and abdominal pain.