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

Answer and Explanation

The Correct Answer is A

A. Interview and physical examination: The two primary methods of data collection in nursing are:

Interview (subjective data: patient history, symptoms, concerns)
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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Correct Answer is D

Explanation

A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.

B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.

C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.

D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.

A. the patient's friends B. past medical records C. the patient's record D. the patient

Correct Answer is D

Explanation

A. The patient's friends: While family and friends can provide secondary information, they are not the primary source of assessment data.

B. Past medical records: Past records can provide valuable history, but they do not replace real-time data from the patient.

C. The patient's record: The medical record is a collection of past documentation but is not a source of new assessment data.

D. The patient: The patient is the primary source of assessment data, as they provide information about their symptoms, medical history, and concerns.

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Identify the two primary methods used to collect data:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Correct Answer is D

Explanation

The primary source of assessment information is:

Correct Answer is D

Explanation

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