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Which of the following examples of patient data needs to be validated? Select all that apply.
- A. A patient has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly patient explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a patient with a respiratory infection documents fever and chills.
- D. A patient in a nursing home states that she is unable to eat the food being served.
- E. A pregnant patient is experiencing contractions that are 2 minutes apart.
- F. Following a MVA, the teenage driver with alcohol on his breath states that he was not drinking.
Correct Answer: A,B,F
Rationale: Data requiring validation includes inconsistencies (A), potential abuse indicators (B), and contradictory statements (F).
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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 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 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.
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.
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.