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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.
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A nurse performs an assessment of a patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
- A. comprehensive
- B. focused
- C. time-lapsed
- D. emergency
Correct Answer: C
Rationale: A time-lapsed assessment compares current data to baseline data collected earlier to evaluate changes.
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.
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).
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 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.