The nurse is assessing a patient with chest pain who has just come to the hospital.
Which open-ended query will provide the nurse with helpful information about the patient's health status?
Are you having any difficulty breathing right now?
How long have you been experiencing chest pain?
What does your chest pain feel like?
Do you have a family history of heart disease?. . .
The Correct Answer is C
Choice A rationale
This is a closed-ended question that requires a yes or no answer. While it gathers specific information about breathing difficulty, it limits the patient's ability to describe their chest pain experience in their own words and provide richer details.
Choice B rationale
This question focuses on the duration of the chest pain. While this is important information for the nurse to know, it does not elicit a description of the pain itself, which is crucial for understanding the potential underlying cause and guiding further assessment.
Choice C rationale
This open-ended question encourages the patient to describe the characteristics of their chest pain, such as its quality (e.g., sharp, dull, crushing), location, radiation, and intensity. This detailed information is vital for differentiating between various causes of chest pain, including cardiac, musculoskeletal, or gastrointestinal issues.
Choice D rationale
While family history is relevant to the patient's overall health status and potential risk factors for certain conditions like heart disease, it does not directly address the patient's immediate experience of chest pain or provide details about the current symptom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Assessing the patient's respiratory status with auscultation of lung sounds and pulse oximetry provides immediate and critical information about the severity of the shortness of breath and the patient's oxygenation. This data is essential for guiding immediate interventions and further assessment. Normal pulse oximetry is typically 95-100%.
Choice B rationale
Telling the patient the physician will be in shortly does not address the immediate distress of acute shortness of breath and delays necessary assessment and intervention. It offers false reassurance without taking any immediate action.
Choice C rationale
While ensuring patient privacy is important, it is not the priority action in a situation of acute shortness of breath. Addressing the immediate physiological compromise takes precedence over privacy concerns at the initial moment of assessment.
Choice D rationale
Reassuring the patient that the shortness of breath will be relieved shortly, without any assessment or intervention, is inappropriate and potentially dangerous. It does not address the underlying cause and may delay necessary treatment.
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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