During the initial interview, Crystal notices that Chuck is grimacing and will not make eye contact with her.
She wants to get more information.
Which ask is most appropriate to help Crystal in her assessment? (Case #2)
Do you need pain medication?
Tell me how are you feeling now?
Do you hurt?
Do you feel like you are going to vomit? . . .
The Correct Answer is B
Choice A rationale
Asking if the patient needs pain medication assumes the grimacing is due to pain. While possible, it doesn't allow the patient to describe their experience fully and may miss other potential causes of their discomfort or non-verbal cues.
Choice B rationale
An open-ended question like "Tell me how are you feeling now?" encourages the patient to articulate their current physical and emotional state in their own words. This allows for a broader understanding of their experience beyond just physical pain and acknowledges the non-verbal cues of grimacing and lack of eye contact.
Choice C rationale
Asking "Do you hurt?" directly focuses on pain, similar to option A. While relevant, it is a closed-ended question that limits the patient's response and may not capture the full spectrum of their discomfort or other issues contributing to their presentation.
Choice D rationale
Asking "Do you feel like you are going to vomit?" focuses on a specific gastrointestinal symptom. While the patient might be experiencing nausea, the grimacing and lack of eye contact could indicate other issues, making this a less comprehensive initial inquiry compared to an open-ended question about their overall feeling. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
While face-to-face hand-off reports are often preferred for direct communication and clarification, they are not always the only acceptable method. Other methods, such as recorded reports or written summaries with opportunities for questions, can also be effective in ensuring continuity of care, especially in situations where face-to-face reporting is not feasible.
Choice B rationale
Providing for the continuity and individualized care of the patient is a primary purpose of hand-off reports. By sharing relevant information about the patient's current condition, care plan, and any recent changes, the hand-off ensures that the receiving nurse has the necessary information to provide consistent and tailored care.
Choice C rationale
Including an opportunity for the receiver to ask questions of the person giving the report is crucial for effective communication and to clarify any ambiguities or obtain additional details. This interactive element helps ensure that the receiving nurse fully understands the patient's situation and can provide safe and appropriate care.
Choice D rationale
Hand-off reports should include up-to-date and recent changes about the patient's condition, treatments, and any new orders or concerns. This ensures that the receiving nurse is aware of the most current information and can adjust care accordingly. Outdated information can lead to errors or omissions in care.
Choice E rationale
Hand-off reports supplement, but do not replace, formal documentation in the patient's medical record. Documentation provides a comprehensive and permanent record of the patient's care, while the hand-off report is a verbal or brief written communication to ensure a smooth transition of care between nurses. Both are essential for effective patient care and communication.
Correct Answer is A
Explanation
Choice A rationale
The nursing process is a systematic, cyclical method used by nurses to identify and address patient health needs. It involves assessment, diagnosis, planning, implementation, and evaluation, providing a structured approach to problem-solving and the delivery of individualized care.
Choice B rationale
Standardized protocols offer guidelines for specific conditions but do not encompass the holistic and individualized nature of the entire nursing process. The nursing process allows for adaptation and critical thinking beyond pre-established routines to meet unique patient needs.
Choice C rationale
A legal document defining the scope of practice outlines what nurses are legally allowed to do. While the nursing process guides nursing actions, it is a framework for care delivery rather than a legal definition of professional boundaries.
Choice D rationale
While communication is integral to healthcare, the nursing process is more than just a communication tool. It is a comprehensive framework that guides all aspects of nursing care, from initial assessment to the evaluation of outcomes, involving critical thinking and clinical judgment.
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