Which of the following statements are true regarding professional standards of nursing assessment? Select all that apply
a. Assessment is a professional nursing responsibility.
b. Assessment helps the nurse identify problems and assign priorities for patient care.
c. Assessment helps the nurse formulate the medical diagnosis.
d. Only patients complaining of pain need to be assessed for pain.
e. Parts of nursing assessments can be delegated according to state practice acts and agency policies.
A, B, E
Assessment is a professional responsibility and assists the nurse to identify problems and prioritize care. Parts of the assessment may be delegated depending on state boards of nursing and agency policies. Assessment helps the nurse formulate a nursing diagnosis; a medical diagnosis is not within the nurse's scope of practice. All patients are assessed for pain.
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After administering medication for an anxiety disorder, it is important for the nurse to record whether the client:
1. Uses caffeine. 2. Takes other medications. 3. Exhibits drowsiness. 4. Uses alcohol.
Which statement best describes preventive health care?
1. It provides people with tools and knowledge to take control of their own health. 2. It is the process of enabling people to be responsible for improving their health and in keeping its personal meaning. 3. It encompasses educational techniques to help people take control of their lives and their health. 4. It is the recognition of the risk for disease and actions taken to reduce that risk.
A woman is 10 weeks pregnant. Her initial prenatal laboratory screening test for rubella showed an antibody titer of less than 1:6 . The woman calls the clinic and tells the nurse that she has been exposed to rubella
The nurse's best response is: A. "Since you are in your first trimester of pregnancy, there is not likely to be a problem." B. "Would you like to see a counselor to talk about your options for the remainder of your pregnancy?" C. "You should come to the clinic in the next day or two for further evaluation." D. "You need to have a rubella vaccination immediately. Can you get a ride to the clinic today?"
Which of the following diseases would the nurse recognize as being caused by a virus? (Select all that apply.)
a. Gonorrhea b. Shingles c. Measles d. Infectious mononucleosis e. Trichomoniasis f. Candida albicans