Identify the two primary methods used to collect data:
interview and physical examination
review of the doctor's orders and the Kardex
written report by patient and family
review of the chart and the nurse's notes
The Correct Answer is A
A. Interview and physical examination: The two primary methods of data collection in nursing are:
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Interview (subjective data: patient history, symptoms, concerns)
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Physical examination (objective data: vital signs, assessment findings)
B. Review of the doctor's orders and the Kardex: This provides supplementary data but does not directly collect patient information.
C. Written report by patient and family: This may provide valuable subjective data but is not a primary method of data collection.
D. Review of the chart and the nurse’s notes: This is reviewing existing documentation, not actively collecting data.
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Related Questions
Correct Answer is B
Explanation
A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.
B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.
C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.
D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.
Correct Answer is B
Explanation
thoroughly. The patient may not have verbalized pain but could still be experiencing it.
B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.
C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).
D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).
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