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
Explanation
Choice A rationale
Client administered nitroglycerin is objective data because it is a documented action performed by the client and can be verified. Subjective data, on the other hand, comes from the client's perspective.
Choice B rationale
Client reports chest pain after mowing the lawn this morning is subjective data because it is a statement made by the client about their experience. It describes their feelings and circumstances as they perceive them.
Choice C rationale
Client's blood pressure is 182/98 mmHg is objective data because it is a measurable physiological parameter obtained through assessment. It is a factual finding that can be directly observed and recorded.
Choice D rationale
Client's skin is pale and diaphoretic is objective data because these are observable physical signs noted by the nurse during assessment. They are factual descriptions of the client's physical condition.
Correct Answer is B
Explanation
Choice A rationale
Sharing information only with family members violates confidentiality unless the patient has provided explicit consent. The Health Insurance Portability and Accountability Act (HIPAA) protects patient health information from unauthorized disclosure, even to family, without patient permission.
Choice B rationale
Adherence to confidentiality principles mandates that healthcare professionals access patient medical records only when there is a legitimate clinical reason related to the provision of care for that specific patient. Accessing records out of curiosity or without a direct care responsibility is a breach of confidentiality.
Choice C rationale
Providing information only to another nurse is too restrictive. Confidentiality allows for the sharing of necessary patient information with all members of the healthcare team directly involved in the patient's care, not just nurses.
Choice D rationale
Providing information only to an attorney is incorrect. While patient records may be disclosed to attorneys in specific legal situations with proper authorization (e.g., subpoena, patient consent), healthcare professionals can also share information with other authorized individuals involved in the patient's care.
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