The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended question will provide the nurse with helpful information about the patient’s health status?
"Are you having any difficulty breathing right now?"
"What does your chest pain feel like?"
"Do you have a family history of heart disease?"
"How long have you been experiencing chest pain?"
The Correct Answer is B
Choice A reason: This is an incorrect choice because "Are you having any difficulty breathing right now?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to describe their condition in detail.
Choice B reason: This is the correct choice because "What does your chest pain feel like?" is an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question invites the patient to describe the quality, intensity, location, and duration of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.
Choice C reason: This is an incorrect choice because "Do you have a family history of heart disease?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to provide more details about their health history or risk factors.
Choice D reason: This is an incorrect choice because "How long have you been experiencing chest pain?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a specific time, and does not encourage the patient to provide more information about their symptoms or situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.
Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.
Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.
Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because accountability is the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Accountability refers to the expectation and requirement to report and explain the actions taken and the results achieved. The nurse is accountable for the accuracy and completeness of the documentation and for the quality and safety of the patient care⁴. By correcting the assessment information, the nurse demonstrates accountability for their own mistake and prevents potential harm to the patient.
Choice B reason: This is an incorrect choice because responsibility is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. The nurse is responsible for conducting and documenting the assessment and for providing appropriate care for the patient⁴. By correcting the assessment information, the nurse is not fulfilling their responsibility, but rather rectifying their error.
Choice C reason: This is an incorrect choice because empowerment is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Empowerment refers to the ability and right of individuals or groups to make their own decisions without interference from others. The nurse is empowered to use their own judgment and expertise to solve problems and improve performance⁴. By correcting the assessment information, the nurse is not exercising their empowerment, but rather admitting their fault.
Choice D reason: This is an incorrect choice because delegation is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Delegation refers to the process of assigning tasks or activities to other staff members based on their scope of practice, competence, and availability. The nurse is responsible for delegating tasks safely and effectively and for supervising and evaluating the delegated staff⁴. By correcting the assessment information, the nurse is not delegating any task, but rather correcting their own work.
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