Unit III Thoughtful practice and the process of care
286
as a basis for nursing and midwifery care. The fact that
this is also hospital policy (
b
) is a secondary reason.
3.
The correct answer is
d
. Perform and document a
focused assessment on skin integrity since this is a
newly identified problem. The initial assessment stands
as is and cannot be redone (
b
) or corrected (
a
). This is
not a life-threatening event, and thus there is no need for
an emergency assessment (
c
).
4.
The correct answer is
b
. Once you learn what consti-
tutes the minimum amount of data required, you can
adapt this to any nursing situation. It is not true that
each assessment is the same even when you are using
the same minimum data set (
a
), or that each assessment
is uniquely different (
c
). Answer
d
is incorrect because
relying solely on standard agency assessment tools
does not allow for individualised person-centred care
or critical thinking.
5.
The correct answer is
a
. A personal report of ‘feeling
nauseated’ cannot be perceived or validated by the nurse/
midwife, and this is subjective data, not objective (
b
) or
overt (
d
), which are observable and measurable. Answer
c
is wrong since signs are examples of objective data.
6.
The correct answer is
d
since the person has the right to
indicate who he would like to be present for the history
and examination. You should neither presume that he
wants his wife there (
a
), nor that he does not want her
there (
c
). Similarly, the choice belongs to the person,
not the wife (
b
).
7.
The correct answer is
d
since it is now common policy
not to use family members as interpreters. The son may
not adequately translate medical information, may not be
trusted to translate what is said without introducing his
bias, and it may not be culturally sensitive to the person
for him to serve in this capacity. Answer
a
is incorrect as
policy prohibits family members from translating, (
b
) is
incomplete and (
c
) also contravenes policy.
8.
The correct answer is
c
. You should first validate your
finding if it is unusual, deviates from normal and is
unsupported by other data. Should your initial recording
prove to be in error, it would have been premature to
notify the charge nurse/midwife (
a
) or the surgeon (
b
).
You want to be sure that all data you record are accu-
rate, so it should be validated before documentation if
you have doubts (
d
).
9.
The correct answer is
a
. Your facilitator is most likely to
challenge your inference that the person is ‘fine’ simply
because she is telling you that she has no problems. It is
appropriate for your facilitator to ask how you validated
this inference. Jumping to the conclusion that the person
does not trust you (
b
) is premature and is an invalidated
inference. Answer
c
is incorrect because it accepts your
invalidated inference and
d
is wrong because it is possi-
ble that the condition is resolving.
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