EXAM 2025
How should the nurse document the patient’s reason for seeking care?
A) JM is a 59-year-old male here for having "black stools" for the past
24 hours.
This response captures the patient's own words and is a precise
reflection of their concern. It provides a clear description of the reason
for seeking medical attention.
What is the best response when a patient reports abdominal pain?
D) "Can you point to where it hurts?"
By asking the patient to point to the pain, the nurse helps localize the
discomfort. This is an essential step in identifying the source of the pain
and understanding its significance.
When a patient mentions back pain, what should the nurse ask next?
,D) "How would you say the pain affects your ability to do your daily
activities?"
This question evaluates the functional impact of the pain on the
patient’s daily life, helping to gauge the severity and determine
appropriate treatment or interventions.
How should a nurse document a patient's denial of childhood illnesses?
D) Patient denies measles, mumps, rubella, chickenpox, pertussis,
rheumatic fever, and polio.
This note is specific and lists all major childhood illnesses, which is
essential for accurate and thorough documentation in the patient's
history.
What is the best follow-up when a patient says they have a penicillin
allergy?
D) "Please describe what happens to you when you take penicillin."
This question allows the nurse to gather detailed information about the
patient's allergic reaction, which is critical for future treatment
decisions.
,Which condition should be asked about in a family medical history?
C) Mental illness.
Mental illness is an important factor in family history, as it can be
hereditary and influence the patient’s overall health. Identifying these
patterns helps with risk assessment and planning care.
Where should information about a patient denying chest pain be
categorized?
D) Review of systems.
The review of systems involves assessing each organ system for any
symptoms or concerns, such as chest pain, which helps provide a
broader understanding of the patient’s health.
Which of the following is subjective data regarding a patient's skin
condition?
C) Denies color change.
, This is subjective data because it is based on the patient's own report of
what they are or are not experiencing with their skin.
Remember that the history (from the chief complaint through review of
systems) should be limited to patient statements or subjective data—
factors that the person says were or were not present.
Subjective data is what the patient tells you.
How would the nurse document the patient’s reason for visiting
regarding a new headache?
"Patient reports 'severe headache' for the past 48 hours."
If a patient reports pain in their chest but is unsure of its location, how
might the nurse follow up?
"Can you describe the type of pain you feel, and does it spread
anywhere else?"
When a patient denies any known medical conditions, what would be
an appropriate way to record this information?
"Patient denies history of hypertension, diabetes, or any chronic
illnesses."