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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.
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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.
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).
Which of the following are characteristics of intimate distance or zone in communication? Select all that apply.
- A. 0 to 18 inches
- B. 18 inches to 4 feet
- C. 4 to 12 feet
- D. involves comforting touch
- E. involves visual distortion
- F. includes professional distance
- G. includes social distance
Correct Answer: A,D,E
Rationale: Intimate distance (0-18 inches) involves close contact, comforting touch, and potential visual distortion due to proximity.
Which of the following entries would be an example of appropriate documentation?
- A. Patient appears depressed and tired.
- B. I am so down today, and I just dont have any energy.
- C. Patient had a good bowel movement.
- D. Complains of abdominal pain. Probably constipated.
Correct Answer: B
Rationale: Appropriate documentation uses the patient's own words to describe their condition accurately.
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.