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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.
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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.
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.
Which theoretical framework is being used when a nurse organizes a nursing history according to functional health patterns?
- A. Body Systems Model
- B. Functional Health Patterns
- C. Maslows Hierarchy of Needs
- D. Orem's Self-Care Model
Correct Answer: A
Rationale: Functional Health Patterns is a framework for organizing nursing history data.
Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?
- A. Why didnt you go to the doctor when you began to have this pain?
- B. Are you feeling better now than you did during the night?
- C. Tell me more about what caused your pain.
- D. If I were you, I would not wait to get medical help next time.
Correct Answer: C
Rationale: Open-ended questions like 'Tell me more' encourage detailed patient responses.
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.