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During a physical examination the nurse discovers that the patient demonstrates signs of flushed dry hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?
- A. Symptoms
- B. Data clustering
- C. Signs of fluid overload
- D. Urinary retention
Correct Answer: B
Rationale: The nurse organizes data, and those that are related are referred to as clustering. These are also signs of fluid overload.
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During an admission assessment the nurse collects objective and subjective data. What is an example of objective data?
- A. The patient complains of feeling depressed.
- B. The patient states "I hear voices in my head."
- C. The patient complains of auditory hallucinations.
- D. The patient is pacing back and forth while chanting.
Correct Answer: D
Rationale: Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data.
What objective data should the nurse include after a patient assessment?
- A. Headache of 3 days' duration
- B. Severe stomach cramps
- C. Flatulence
- D. Anxiety
Correct Answer: C
Rationale: Objective data are observable and measurable by people other than the patient.
What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
- A. Erikson's developmental tasks
- B. Piaget's cognitive table
- C. Maslow's hierarchy of needs
- D. Freud's classifications
Correct Answer: C
Rationale: A useful framework to guide prioritization is Maslow's hierarchy of needs.
All of the following patients have been admitted to the acute care setting. On admission which patient should receive a focused assessment?
- A. 53-year-old admitted with a perforated ulcer
- B. 5-year-old admitted for the implant of grommets in the middle ear
- C. 76-year-old admitted for a knee replacement
- D. 40-year-old admitted for possible bowel obstruction
Correct Answer: A
Rationale: A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.
A systematic method by which nurses plan and provide care for patients is known as the nursing ____
Correct Answer: process
Rationale: The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients.