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Who or what is the primary source of information for a nursing history?
- A. previous medical records
- B. other healthcare personnel
- C. the patient
- D. family members
Correct Answer: C
Rationale: The patient is the primary source for a nursing history, providing firsthand information about their health.
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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.
On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?
- A. the pathology of the illness
- B. the response of the patient to the illness
- C. information from a nursing textbook
- D. knowledge from more experienced nurses
Correct Answer: B
Rationale: Nursing diagnoses focus on the patient's response to health conditions, such as chronic pain, rather than the medical pathology.
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.
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.
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.