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 B
Explanation
Choice A rationale
While electronic medical record (EMR) systems aim to improve legibility by using standardized digital documentation, they do not entirely eliminate the need to interpret physician notes or other entries. There may still be instances where clarification or interpretation is required.
Choice B rationale
A significant benefit of implementing an EMR system is the potential to streamline documentation processes. Electronic charting can reduce the time nurses spend on manual tasks such as handwriting notes, transcribing orders, and locating paper records, thereby improving efficiency.
Choice C rationale
Password management and security protocols are often a necessary component of electronic systems to protect patient privacy and data integrity. Implementing a new EMR system may involve changes to password policies and frequency of updates, which could be a source of frustration rather than a benefit.
Choice D rationale
Access to a family member's medical record, even a child's, raises significant privacy and security concerns. Healthcare systems have strict regulations (e.g., HIPAA) to protect patient confidentiality, and nurses typically do not have unrestricted access to family members' records.
Correct Answer is B
Explanation
Choice A rationale
Maintaining a normal respiratory rate (typically 12-20 breaths per minute for adults) and pulse rate (typically 60-100 beats per minute for adults) are general indicators of stable physiological function but do not directly confirm airway clearance. While improved airway clearance can contribute to these stable vital signs, other factors can also influence them.
Choice B rationale
A clear airway directly addresses the nursing diagnosis of ineffective airway clearance. If the patient's airway remains unobstructed, thick sputum can be expectorated or managed, and narrowed airways will not impede airflow. This outcome specifically targets the problem identified in the nursing diagnosis.
Choice C rationale
Resting comfortably by the morning is a desirable outcome reflecting overall well-being, but it is not a direct measure of airway clearance. While improved breathing can contribute to comfort, other factors like pain or anxiety can also affect rest.
Choice D rationale
Absence of shortness of breath (dyspnea) and anxiety suggests improved respiratory function, but it doesn't definitively confirm the airway is clear of thick sputum or that narrowed airways are no longer a problem. The patient could still have airway issues without experiencing these symptoms consistently.
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