Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

a head-to-toe assessment

subjective data collection

objective data collection

Maslow's Hierarchy of Needs

Coughed up 5 mL yellow sputum

Answer and Explanation

The Correct Answer is A

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

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Correct Answer is C

Explanation

A. Ensure subjective documentation: JCAHO (Joint Commission on Accreditation of Healthcare Organizations) promotes objective documentation to ensure accuracy and reliability in patient care records.

B. Make sure that all nurses use the same charting system: JCAHO does not mandate a uniform charting system, as institutions may use different electronic health record (EHR) systems.

C. Ensure quality patient care: JCAHO’s primary role is to establish and enforce standards to improve patient safety and healthcare quality.

D. Make sure insurance companies get paid correctly: JCAHO’s focus is on patient care quality, not financial reimbursement.

A. the patient is vulnerable to develop the problem B. there is no evidence of defining characteristics C. a condition is currently present D. it is written as a two-part statement

Correct Answer is C

Explanation

A. The patient is vulnerable to develop the problem: This describes a risk diagnosis, where the patient has the potential to develop a condition but does not currently have it.

B. There is no evidence of defining characteristics: An actual nursing diagnosis must have defining characteristics (symptoms/signs).

C. A condition is currently present: An actual nursing diagnosis means the condition is already present, with observable signs and symptoms.

D. It is written as a two-part statement: Actual nursing diagnoses use a three-part statement:

Problem (diagnosis)
Etiology (cause)
Signs and Symptoms (evidence)

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Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

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Naxlex Comprehensive Predictor Exams

JCAHO regulates standards of care to:

Correct Answer is C

Explanation

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Correct Answer is C

Explanation

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Which of the following assists the nurse in the identification of nursing diagnoses?

The primary source of assessment information is:

When documenting events in a patient's chart, the nurse should chart:

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

Who should document care in the patient record?

Identify the two primary methods used to collect data: