Which is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain?
"Did someone come to the hospital with you?"
"When did your chest pain begin?"
"Did your family doctor tell you to come to the hospital?"
"Do you have a family history of heart disease?"
The Correct Answer is B
Choice A reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Choice B reason: This is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is relevant, open-ended, and comprehensive. The nurse should ask questions that are related to the patient's health status, needs, or goals, and that elicit more information from the patient. This question allows the patient to describe the onset, duration, and frequency of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.
Choice C reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Choice D reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Cleaning the fixed IV pump and returning it to the floor can cause harm to the patient or the staff if the pump is used again.
Choice B reason: This is correct. Tagging the IV pump and removing it from the area prevents the pump from being used by mistake and alerts the maintenance staff to repair or replace it.
Choice C reason: This is incorrect. Contacting the IV pump manufacturer is not the role of the nurse. The nurse should report the malfunction to the appropriate person in the facility.
Choice D reason: This is incorrect. Initiating a work order on the IV pump is not enough to ensure the safety of the patient and the staff. The pump should be tagged and removed from the area as well.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because perceived constipation related to expectation of daily bowel movements is not an appropriate nursing diagnosis for this patient. Perceived constipation is a subjective problem that occurs when the patient's bowel elimination pattern does not meet their personal expectations. The patient may not have any objective signs of constipation, such as hard stools, straining, or abdominal discomfort. This diagnosis is not applicable to this patient, who has objective signs of constipation and a clear cause of the problem.
Choice B reason: This is an incorrect choice because impaired bowel elimination related to abdominal muscle weakness is not an appropriate nursing diagnosis for this patient. Impaired bowel elimination is a problem that occurs when the patient has difficulty in passing stools or has a change in bowel habits. Abdominal muscle weakness is a possible factor that can affect bowel function, but it is not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who has a normal muscle strength and a clear cause of the problem.
Choice C reason: This is an incorrect choice because risk for constipation related to irregular defecation habits is not an appropriate nursing diagnosis for this patient. Risk for constipation is a potential problem that occurs when the patient is vulnerable to developing constipation due to various factors. Irregular defecation habits are a possible factor that can increase the risk of constipation, but they are not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who already has constipation and a clear cause of the problem.
Choice D reason: This is the correct choice because constipation related to side effects of pain medication is an appropriate nursing diagnosis for this patient. Constipation is a problem that occurs when the patient has infrequent, difficult, or incomplete bowel movements. Pain medication, especially opioids, are a common cause of constipation, as they can slow down the gastrointestinal motility and reduce the stool volume and water content. This diagnosis is applicable to this patient, who has objective signs of constipation and a clear cause of the problem..
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