Nokea
The patient is confined to bed rest which contributes to immobility. What is bed rest considered in this situation?
- A. Contributing to the patient's recovery
- B. A risk factor
- C. Difficult to maintain
- D. A nursing responsibility
Correct Answer: B
Rationale: Risk factors are those that increase the susceptibility of a patient to a problem.
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Human responses to levels of wellness in an individual family or community that have a readiness for enhancement are known as a ____ patient problem
Correct Answer: wellness
Rationale: A wellness patient problem is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement.
Which are acceptable secondary sources for data?
- A. Patient
- B. Family members
- C. Other health professionals
- D. Diagnostic reports
- E. Textbooks
Correct Answer: B,C,D,E
Rationale: A patient is not a secondary source. The patient is the primary data source.
What is the basis for designing and selecting nursing interventions to meet patient needs?
- A. Patient problem
- B. Care plan
- C. Health care provider's orders
- D. Nurse's notes
Correct Answer: A
Rationale: The patient problem is the basis for developing nursing interventions.
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.
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.