Nokea
Objective components of an initial assessment database would include some, but not all, of the following. Which components would not be considered objective?
- A. Blood pressure, temperature, pulse, respirations, and oxygen saturation level
- B. Pain level, location, and characteristics
- C. Level of consciousness
- D. Auscultation of heart, breath, and bowel sounds
- E. Peripheral pulses and capillary refill
- F. Range of motion and strength of all extremities
- G. Weight and height
Correct Answer: B
Rationale: Pain is subjective as it relies on patient self-reporting. All other options are measurable and observable, making them objective.
You may also like to solve these questions
Which of the following would NOT be a therapeutic nursing intervention that demonstrates respect and compassion for patients' common reactions to admission?
- A. Smiling when meeting a new patient
- B. Explaining what you are going to do prior to doing it
- C. Encouraging the patient to ask questions
- D. Explaining to the patient that there is no need to be embarrassed when you expose his or her body
Correct Answer: D
Rationale: Minimizing a patient's embarrassment may dismiss their feelings. Smiling, explaining procedures, and encouraging questions show respect and compassion.
Ways to reduce separation anxiety in an older adult might include which of the following?
- A. Providing the patient with a brief but factual explanation of his or her diagnosis and why he or she must be in the hospital.
- B. Explaining that visiting hours do not allow someone to stay with an adult.
- C. Reassuring the patient whenever possible without giving false reassurance.
- D. Allowing a spouse or family member to stay with the patient.
Correct Answer: A,C,D
Rationale: Clear explanations, reassurance, and family presence help alleviate anxiety in older adults. Restrictive visiting hours may increase anxiety, so option B is incorrect.
Which of the following data would not be appropriate to include on a transfer summary form?
- A. A list of patient's discharge medications
- B. A note describing how difficult it is to get the patient to take medications
- C. Current diet order and activity restrictions
- D. Patient teaching that has been done and the patient's response
- E. Follow-up appointments
Correct Answer: B
Rationale: Subjective opinions about patient behavior are inappropriate. Objective data like medications, diet, teaching, and appointments are relevant.
After explaining a test or procedure to the patient, you would observe for both objective and subjective signs of understanding or confusion, which will indicate whether or not your patient teaching was effective. This is known as which phase of the nursing process?
- A. Planning
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Evaluation assesses the effectiveness of teaching by observing patient understanding.
Which of the following should be included in your last nurse's notes entry at discharge?
- A. The patient's condition
- B. Vital signs
- C. The time the patient actually leaves
- D. The method of transportation
- E. Notification of housekeeping
Correct Answer: A,B,C,D
Rationale: The final note should document the patient's condition, vital signs, departure time, and transportation method. Notifying housekeeping is not included in nurse's notes.