Ch. 14

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 fevers 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 two minutes apart F) following a MVA, the teenage driver with alcohol on his breath states that he was not drinking

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 F) following a MVA, the teenage driver with alcohol on his breath states that he was not drinking

A nurse who collected and organized data during a patient history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies B) The nurse should modify data collection tool C) The nurse should determine specific purpose of data collection D) The nurse should review and practice communication techniques

A) The nurse should practice interviewing strategies

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

A) findings of the physicians assessment and treatment

One of the residents begins to choke and is unable to breathe. The nurse assesses the residents ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) to identify a life-threatening problem B) to establish a database for medical care C) to practice respiratory assessment skills D) to facilitate the residents ability to breathe

A) to identify a life-threatening problem

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 don't have any energy C) patient had a good bowel movement D) complains of abdominal pain, probably constipated

B) I am so down today, and I just don't have any energy

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

C) collection, validation, communication of patient data

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

C) the patient

A nurse performs an assessment 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

C) time-lapsed

A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply A) caring out a physicians order to intubate a patient B) teaching a novice nurse the principles of triage C) using the nursing process to diagnose a blocked airway D) interviewing a patient suspected of being a victim of abuse privately E) checking the data supplied by a patient with dementia with the family F) teaching a diabetic patient about the importance of proper footcare

C) using the nursing process to diagnose a blocked airway D) interviewing a patient suspected of being a victim of abuse privately E) checking the data supplied by a patient with dementia with the family

A nurse is preparing to conduct a health history for a patient who is confined to the bed. How should the nurse position herself? A) standing at the end of the bed B) standing at the side of the bed C) sitting at least 6 feet from the bedside D) sitting at a 45° angle to the bed

D) sitting at a 45° angle to the bed

What is the primary purpose of validation as part of assessment? A) to identify data to be validated B) to establish an effective nurse patient communication C) to maintain effective relationships with coworkers D) to plan appropriate nursing care

D) to plan appropriate nursing care