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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.
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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.
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.
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.
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.
A student takes an adult patients pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?
- A. Record the pulse rate on the appropriate vital signs sheet in the chart.
- B. Ask the instructor or a staff nurse to take the pulse.
- C. Discuss this finding during postconference with other students.
- D. Wait 4 hours and take the patients pulse again.
Correct Answer: B
Rationale: An abnormal finding like a pulse of 20 beats/min requires immediate verification by a qualified professional.