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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.
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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.
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.
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 statements best describes the relationship between nursing diagnosis and medical diagnosis?
- A. The nursing diagnosis confirms the medical diagnosis.
- B. The nursing diagnosis duplicates the medical diagnosis.
- C. There is no relationship between nursing and medical diagnoses.
- D. The nursing diagnosis is based on patient response to the medical diagnosis.
Correct Answer: D
Rationale: Nursing diagnoses address the patient's response to the medical condition, distinct from the medical diagnosis itself.
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.