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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.
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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.
A nurse who collected and organized data during a patient history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?
- A. The nurse should practice interviewing strategies.
- B. The nurse should modify data collection tool.
- C. The nurse should determine specific purpose of data collection.
- D. The nurse should review and practice communication techniques.
Correct Answer: A
Rationale: Practicing interviewing strategies improves data collection thoroughness.
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.
A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself?
- A. standing at the end of the bed
- B. standing at the side of the bed
- C. sitting at least 6 feet from the beside
- D. sitting at a 45-degree angle to the bed
Correct Answer: D
Rationale: Sitting at a 45-degree angle facilitates eye contact and communication with a bedridden patient.
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
- A. My leg hurts so bad. I cant stand it.
- B. Appears anxious and frightened.
- C. I am so sick; I am about to throw up.
- D. Unable to palpate femoral pulse in left leg.
Correct Answer: D
Rationale: Objective data are measurable findings, such as the inability to palpate a pulse.