Answer to Question 1
Correct Answer: 3
Rationale 1: The baby's birth record able to provide necessary information, but not to the extent as the parents.
Rationale 2: While the grandmother can support the parents during this time and may be able to offer some helpful information she would not be the best source.
Rationale 3: The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. Even though the parents are upset, they would be able to provide the nurse with the most accurate, current information regarding the baby (diet, schedule, symptoms, etc.).
Rationale 4: The admitting physician will be able to provide necessary information, but not to the extent as the parents.
Answer to Question 2
Correct Answer: 4
Rationale 1: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 1 hour.
Rationale 2: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 12 hours.
Rationale 3: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 48 hour.
Rationale 4: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within 24 hours of admission as an inpatient.