Order nursing history assessment

Order nursing history assessment
3. a. Though it may be true that you need to develop
assessment skills (c), the chief reason you are doing
a nursing history and exam is because there needs to
be a documented nursing admission assessment to
serve as a basis for nursing care. The fact that this is
also hospital policy (b) is a secondary reason.
4. d. Perform and document a focused assessment
on skin integrity since this is a newly identified
problem. The initial assessment stands as is and
cannot be redone (b) or corrected (a). This is not a
life-threatening event; thus, there is no need for an
emergency assessment (c).
5. b. Once you learn what constitutes the minimum data
set, you can adapt this to any patient situation. It is not
true that each assessment is the same even when you
are using the same minimum data set (a), nor is it true
that each assessment is uniquely different (c). Answer d
is incorrect because relying solely on standard agency
assessment tools does not allow for individualized
patient care or critical thinking.
6. a. A patient report of “feeling nauseated” cannot be per-
ceived or validated by the nurse, and this is subjective
data, not objective (b) or overt (d), which are observable
and measurable. Answer c is wrong because signs are
examples of objective data.
7. d. The patient has the right to indicate who he
would like to be present for the nursing history and
exam. You should neither presume that he wants his
wife there (a), nor that he does not want her there (c).
Similarly, the choice belongs to the patient, not the
wife (b).
8. d. Even if the son is able and willing to translate,
best practice now dictates using approved translators.
Family dynamics often make discussions about the
intimate details of medical conditions and treatment
difficult.
9. c. You should first validate your finding if it is
unusual, deviates from normal, and is unsupported
by other data. Should your initial recording prove
to be in error, it would have been premature to notify
the charge nurse (a) or the surgeon (b). You want
to be sure that all data you record is accurate, so it
should be validated before documentation if you
have doubts (d).
10. a. Your instructor is most likely to challenge your infer-
ence that the patient is “fine” simply because he is
telling you that he has no problems. It is appropriate for
her to ask how you validated this inference. Jumping to
the conclusion that the patient does not trust you (b) is
premature and is an invalidated inference. Answer c is
wrong because it accepts your invalidated inference.
Answer d is wrong because it is possible that the condi-
tion is resol