Nokea
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).
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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.
Which of the following questions or statements would be an appropriate termination of the health history interview?
- A. Well, I cant think of anything else to ask you right now.
- D. I'm going to step out for a moment, but I'll be back to discuss next steps.
Correct Answer: B
Rationale: A professional closing statement maintains rapport and sets expectations for follow-up.
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.
A nurse performs an assessment of a patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
- A. comprehensive
- B. focused
- C. time-lapsed
- D. emergency
Correct Answer: C
Rationale: A time-lapsed assessment compares current data to baseline data collected earlier to evaluate changes.
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.