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The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?
- A. Have a family member provide the data.
- B. Obtain the data from the old chart and physicians assessment.
- C. Obtain the data only from the patient, prioritizing aspects that the patient understands.
- D. Collect all possible data from the patient and have the family supplement missing details.
Correct Answer: D
Rationale: The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient. In this case, it is not likely possible to get all the information needed only from the patient.
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A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize?
- A. Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity
- B. Increasing her BMI, taking a multivitamin, and discussing body image
- C. Increasing calcium intake, eating a balanced diet, and discussing eating disorders
- D. Obtaining a food diary along with providing close monitoring for anorexia
Correct Answer: C
Rationale: Adolescent girls are considered to be at high risk for nutritional disorders. Increasing calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals. If adolescents are diagnosed with eating disorders early, the recovery chances are increased. The question presents no information that indicates a need for decreasing her calories. There is no apparent need for an increase in BMI. A food diary is used for assessing eating habits, but the question asks for teaching factors related to good nutrition.
You are the emergency department nurse obtaining a health history from a patient who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should you ask to elicit the probable reason for the visit and identify her chief complaint?
- A. Why do you think your abdomen is painful?
- B. Where exactly is your abdominal pain and when did it start?
- C. What brings you to the hospital today?
- D. What is wrong with you today?
Correct Answer: C
Rationale: The chief complaint should clearly address what has brought the patient to see the health care provider; an open-ended question best serves this purpose. The question What brings you to the hospital? allows the patient sufficient latitude to provide an answer that expresses the priority issue. Focusing solely on abdominal pain would be too specific to serve as the first question regarding the chief complaint. Asking, What is wrong with you today? is an open-ended question but still directs the patient toward the fact that there is a problem.
You are conducting an assessment of a patient in her home setting. Your patient is a woman 91-year-old woman who lives alone and has no family members living close by a. What would you need to be aware of to aid in providing care to this patient?
- A. Kreutzer Where the closest relative lives
- B. What resources are available to the patient
- C. What is the patient's financial status
- D. How many children live nearby
- E. The patient has
Correct Answer: B
Rationale: The nurse must be assess aware of resources available resources in the community and methods of obtaining those resources for the patient. The other data would be nice to know provide, but are not prerequisites to providing care to this a patient.
The nurse is performing the process of inspection during an assessment. What nursing action should the nurse include during this phase?
- A. Gather as many psychosocial details as possible.
- B. Pay attention to the details while observing.
- C. Write down as many details as possible during the observation.
- D. Do not let the patient know he is being assessed.
Correct Answer: B
Rationale: It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. It is specific information, not general information, that is being gathered. Writing while observing can be a conflict for the nurse. It is not necessary or appropriate to keep the assessment concealed from the patient.
You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history?
- A. The patient may be at risk for developing diabetes.
- B. The patient may need teaching on the effects of diabetes.
- C. The patient may need to attend a support group for individuals with diabetes.
- D. The patient may benefit from a dietary regimen that tracks glucose intake.
Correct Answer: A
Rationale: Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin. The results of diabetes testing would determine whether dietary changes, support groups or health education would be needed.