When is nursing assessment most complete?
1. When insight is gained through an assessment of individual needs before the needs of the family
2. When insight is gained through an assessment of the family needs before the needs of the individual
3. When insight is gained through an assessment of the needs of the individual and family simultaneously
4. When insight is gained through an individual-nurse-family relationship with consideration of the surrounding community
ANS: 4
Rationale:
Nursing assessment is most effective when nurses complete every assessment with ideas gained through an individual-nurse-family relationship enacted with consideration of the surrounding community.
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The medical director of hospital has received several requests for patient transfers to other facilities
Based on the Emergency Medical Transfer Active Labor Act, which of the following cases would justify interfacility transfer? Select all that apply. A) A patient requires emergency coronary angioplasty and the sending hospital is not equipped to perform this service. B) The family of a patient severely injured in a car wreck in another state requests that the patient be transferred to a facility where they live. C) The administration of the hospital requests that a patient who lacks health insurance be transferred to a facility that can better absorb the cost of his care. D) A surgeon at the receiving hospital has unique experience performing a procedure that the patient requires.
The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.)
a. "Let me know if Mr. Smith's blood pressure is low." b. "Take Mrs. Jones' blood pressure every 15 minutes." c. "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg." d. "Do you want me to demonstrate using the electronic blood pressure cuff?" e. "I'll take Mr. Derby's blood pressure since he is not stable."
To provide the best care to a client having pain, the nurse must assess which information in addition to using a pain measuring scale?
a. A record of any healing taking place in damaged tissue b. Objective measurements of the tissue damage c. The client's perception of the pain d. The type of pain fibers conducting the pain
A 54-year-old patient is admitted to the hospital in the final stage of chronic lymphocytic leukemia (CLL). Which of the following manifestations of CLL would the nurse expect to find while collecting admission data?
a. Nausea and vomiting b. Hypotension and alopecia c. Cervical lymphadenopathy and chest pain d. Fever and abnormal bleeding