A focused assessment should be done by the nurse in all of the following situations EXCEPT:
patient's vital signs are B/P 120/80, P 88 and R 18
non-responsive patient
disoriented patient
critically patient ill
The Correct Answer is A
A. Patient’s vital signs are B/P 120/80, P 88, and R 18: Stable, normal vital signs do not indicate an immediate need for a focused assessment unless there is a complaint or concern.
B. Non-responsive patient: A focused neurological and airway assessment is required for an unresponsive patient.
C. Disoriented patient: Disorientation may indicate neurological issues, infection, or metabolic imbalance, requiring a focused mental status and neurological assessment.
D. Critically ill patient: Critically ill patients require frequent focused assessments based on their condition (e.g., respiratory, cardiac, or neurological).
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Related Questions
Correct Answer is C
Explanation
A. It increases cost.: While initial implementation is costly, computerized charting ultimately reduces costs by improving efficiency and reducing errors.
B. It promotes individualization of the medical record.: Computerized systems standardize documentation rather than individualizing it. However, personalization can be added through specific notes.
C. It improves legibility.: Handwritten notes can be illegible, leading to errors. Computerized charting eliminates handwriting issues and ensures clarity.
D. It minimizes the number of forms to be completed.: While it may reduce paperwork, it does not necessarily minimize documentation, as structured data entry is still required.
Correct Answer is ["C","D","E"]
Explanation
A. Assistive personnel reports the patient walks with a limp: This is secondhand information (reported by UAP), not directly observed by the nurse.
B. Patient reports pain level as 3 on a scale of 1 to 10: Pain is subjective data because it is based on the patient's self-report.
C. Heart rate 72 beats per minute: Heart rate is measured by the nurse, making it objective data.
D. Respiratory rate 22 per minute with even unlabored respirations: The nurse directly observes and measures respiratory rate, making it objective data.
E. Coughed up 5 mL yellow sputum: The nurse can observe and quantify the sputum (color and volume), making it objective data.
F. Headache in frontal area: A headache is subjective data because only the patient can describe it.
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