While conducting an assessment of the patient, the nurse recognizes that after verifying biographical data, the initial step is:
the nursing health history
a body systems review
the present illness
a focused review
The Correct Answer is A
A. The nursing health history – The nursing health history is the first step after collecting biographical data. It includes the chief complaint, past medical history, and social factors affecting health.
B. A body systems review – A body systems review (ROS) is done later in the assessment to gather additional information on each organ system.
C. The present illness – The present illness is part of the nursing health history but is not the first step after verifying biographical data.
D. A focused review – A focused review targets specific concerns rather than serving as the initial step in a comprehensive assessment.
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Related Questions
Correct Answer is A
Explanation
A. Is a protective response – Inflammation is a natural immune response that helps contain injury and promote healing, regardless of infection.
B. Is a disease process – Inflammation itself is not a disease; it is a response to injury, infection, or irritation.
C. Produces tissue damage – While excessive or chronic inflammation can cause tissue damage, inflammation itself is not inherently destructive.
D. Is a result of bacteria – Inflammation can be caused by bacteria, viruses, trauma, or autoimmune conditions, not just bacterial infection.
Correct Answer is B
Explanation
A. Head-to-toe assessment – A head-to-toe assessment is a comprehensive evaluation of all body systems and is not appropriate for an urgent complaint.
B. Focused assessment – A focused assessment is used for specific complaints, such as severe abdominal pain, to quickly gather relevant information.
C. Complete assessment –. A complete assessment includes a full health history and physical examination, which is unnecessary in an acute situation.
D. System-by-system assessment – A system-by-system assessment is detailed and comprehensive but may be too broad for addressing an immediate concern.
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