Nokea
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.
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The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
- A. to gather data about a specific and current health problem
- B. to identify life-threatening problems that require immediate attention
- C. to compare and contrast current health status to baseline data
- D. to establish a database to identify problems and strengths
Correct Answer: D
Rationale: An initial assessment creates a comprehensive database to identify patient problems and strengths for planning care.
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).
A nurse is collecting information from Mr. Koeppe, a patient with dementia. The patients daughter, Sarah, accompanies the patient. Which of the following statements by the nurse would recognize the patients value as an individual?
- A. Sarah, can you tell me how long your father has been this way?
- B. Sarah, I have to go and read your fathers old charts before we talk.
- C. Mr. Koeppe, tell me what you do to take care of yourself.
- D. Mr. Koeppe, I know you cant answer my questions, but its okay.
Correct Answer: C
Rationale: Addressing the patient directly respects their individuality and encourages their participation.
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.
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.