When the nurse begins the shift on an acute care unit, each patient is to be reassessed, and documentation of patient care completed. The nurse plans additional reassessment of patients to occur with which frequency?

At least every 24 hours

Based on the patient's condition

Before each physician's visit

At the nurse's discretion

Answer and Explanation

The Correct Answer is B

Clinical assessment is a dynamic process involving the systematic collection of objective and subjective data to evaluate patient progress. Nurses utilize clinical judgment to detect subtle changes in physiological status, ensuring that the frequency of monitoring aligns with the patient's hemodynamic stability and acuity level.

Rationale:

A. Assessing a patient only once every 24 hours is insufficient in an acute care setting. Physiological status can deteriorate rapidly within minutes or hours, making such a long interval unsafe. Standard acute care protocols typically require assessments at least every 8 hours or shiftly.

B. The frequency of nursing reassessment must be individualized based on the patient's current clinical condition and stability. An unstable patient requires continuous or high-frequency monitoring, whereas a stable patient may only require assessments at standard intervals. This ensures patient safety through early detection of complications.

C. Timing assessments solely based on the physician's visit is reactive rather than proactive nursing care. Nurses must maintain independent surveillance to ensure that any change in status is addressed immediately. Waiting for a provider's arrival could delay critical interventions for a declining patient.

D. While nurses have professional autonomy, the frequency of assessment should be guided by evidence-based protocols and the patient's needs rather than simple discretion. Using clinical status as the primary determinant provides a standardized approach to monitoring. Discretion without clinical justification can lead to negligent oversight.

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Correct Answer is B

Explanation

Community health nursing is grounded in population-focused care, epidemiology, health promotion, and aggregate health assessment, where the nurse provides services to defined groups sharing common characteristics, geographic location, social structures, or health-related needs to improve overall community health outcomes.

Rationale:

A. Continuum of care refers to the integration of healthcare services over time and across settings, such as hospital, home care, and rehabilitation. It describes service coordination rather than a group of individuals sharing common characteristics or goals.

B. Community is the correct term. It refers to a group or aggregate of individuals who share common interests, values, characteristics, or geographic location and interact within social systems. This is the primary focus of community health nursing practice.

C. Patients’ home refers to a physical care setting, not a population group. While home may be a site for community health nursing services, it does not define a collective group of individuals with shared characteristics or goals.

D. Holistic care refers to an approach to nursing care that addresses physical, emotional, social, and spiritual needs of an individual. It is a philosophy of care, not a term used to describe a population or group.

A. Sends the PCA to ask if the patient is having dizziness B. Writes down what the patient says, avoids eye contact, and tells the patient they will be alright C. Utilizes open-ended questions to elicit more information D. Turns away from the patient as the patient describes symptoms to the nurse

Correct Answer is C

Explanation

Therapeutic communication in nursing is based on patient-centered interviewing, active listening, verbal facilitation techniques, and information exploration strategies, which promote accurate data collection, patient trust, and comprehensive understanding of symptoms such as vertigo, which may have vestibular, neurological, or cardiovascular origins.

Rationale:

A. Sending a PCA to assess dizziness is inappropriate because it bypasses the nurse–patient therapeutic relationship and delegates assessment communication in a non-therapeutic and clinically unsound manner. It also risks inaccurate symptom interpretation without nursing assessment.

B. Writing notes while avoiding eye contact and giving reassurance without assessment limits therapeutic engagement. This behavior reflects non-therapeutic communication, reduces patient trust, and prevents exploration of symptom characteristics necessary for clinical evaluation of vertigo.

C. Using open-ended questions is the most therapeutic approach because it encourages detailed patient responses, promotes elaboration of symptom characteristics such as onset, duration, triggers, and associated symptoms, and enhances accurate clinical data collection during nursing assessment.

D. Turning away from the patient demonstrates non-verbal disengagement and lack of active listening. This behavior decreases rapport, limits patient disclosure, and interferes with effective therapeutic communication needed to assess complex symptoms like vertigo.

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When the nurse begins the shift on an acute care unit, each patient is to be reassessed, and documentation of patient care completed. The nurse plans additional reassessment of patients to occur with which frequency?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The community health nurse provides services to a group or collection of individuals interacting in social units and sharing common interests, characteristics, values, and goals. What terminology would the nurse use to describe this group?

Correct Answer is B

Explanation

The nurse listens to a patient relating to precipitating factors that led to the vertigo. Which approach by the nurse would be most therapeutic when eliciting additional information during the interview?

Correct Answer is C

Explanation

A staff nurse serves as a member of the hospital's disaster team. Every 3 months, the team tests its disaster plan by practicing for a mass casualty incident. Which role is this drill preparing the nurse for?

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