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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.
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A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, I have been so constipated lately. How should the nurse respond?
- A. Do you have a family history of chest problems?
- B. Why dont you use a laxative every night?
- C. Do you take anything to help your constipation?
- D. Everyone who ages has bowel problems.
Correct Answer: C
Rationale: Asking about current management of the symptom encourages relevant information.
Which of the following group of terms best defines assessing in the nursing process?
- A. problem focused, time lapsed, emergency based
- B. design a plan of care, implement nursing interventions
- C. collection, validation, communication of patient data
- D. nurse focused, establishing nursing goals
Correct Answer: C
Rationale: Assessing in the nursing process involves gathering, verifying, and sharing patient information to inform care decisions.
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.
Who or what is the primary source of information for a nursing history?
- A. previous medical records
- B. other healthcare personnel
- C. the patient
- D. family members
Correct Answer: C
Rationale: The patient is the primary source for a nursing history, providing firsthand information about their health.
Which of the following questions or statements would be an appropriate termination of the health history interview?
- A. Well, I cant think of anything else to ask you right now.
- D. I'm going to step out for a moment, but I'll be back to discuss next steps.
Correct Answer: B
Rationale: A professional closing statement maintains rapport and sets expectations for follow-up.