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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.
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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.
What type of patient record data would the nurse find in the medical history and progress notes?
- A. findings of the physicians assessment and treatment
- B. results of laboratory and diagnostic studies
- C. nursing documentation and plan of care
- D. information from other members of the healthcare team
Correct Answer: A
Rationale: Medical history and progress notes contain physician assessments and treatment plans.
A nurse is collecting data from a home care patient. In addition to information about the patients health status, what is another observation the nurse should make?
- A. number of rooms in the house
- B. safety of the immediate environment
- C. frequency of home visits to be made
- D. friendliness of the patient and family
Correct Answer: B
Rationale: Assessing environmental safety is critical in home care to prevent risks like falls.
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).
What is the primary purpose of validation as a part of assessment?
- A. to identify data to be validated
- B. to establish an effective nursepatient communication
- C. to maintain effective relationships with coworkers
- D. to plan appropriate nursing care
Correct Answer: D
Rationale: Validation ensures accurate data for effective care planning.