A nurse is conducting an initial assessment for a client who was admitted with pneumonia. Which of the following actions should the nurse take during this phase of the nursing process?

Establish a baseline for planning care and evaluating outcomes.

Identify the client's response to health concerns or illness.

Provide goal-directed, client-centered care.

Compare the client's data with expected standards or reference ranges.

Answer and Explanation

The Correct Answer is A

Choice A reason:.

Establishing a baseline for planning care and evaluating outcomes is the main purpose of the assessment phase of the nursing process. The assessment phase involves collecting data about the client's health status and needs, which will help the nurse to identify any problems or potential problems that may need to be addressed. The assessment data will also serve as a reference point for comparing the client's progress and outcomes throughout the nursing process.

Choice B reason:.

Identifying the client's response to health concerns or illness is part of the diagnosis phase of the nursing process. The diagnosis phase involves analyzing the data collected during the assessment phase and identifying the client's problems and strengths. The nurse then formulates a nursing diagnosis, which is a statement of the client's actual or potential health problem that can be addressed by nursing interventions.

Choice C reason:.

Providing goal-directed, client-centered care is part of the planning and implementation phases of the nursing process. The planning phase involves setting goals and outcomes for the client and selecting appropriate interventions to achieve them. The goals and outcomes should be specific, measurable, attainable, realistic, and timely (SMART), and they should reflect the client's preferences and values. The implementation phase involves carrying out the interventions and documenting the actions and responses. The interventions should be evidence-based, safe, and effective, and they should involve the client as much as possible.

Choice D reason:.

Comparing the client's data with expected standards or reference ranges is part of the evaluation phase of the nursing process. The evaluation phase involves evaluating the effectiveness of the interventions and modifying the plan as needed. The nurse compares the client's actual outcomes with the expected outcomes and determines whether the goals have been met, partially met, or not met. The nurse also identifies any factors that may have influenced the outcomes, such as client compliance, environmental factors, or unexpected events.

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Correct Answer is A

Explanation

Choice A reason:

Asking the client when they first noticed the symptoms is a relevant and appropriate question for a problem-focused assessment. It helps the nurse to determine the onset, duration, and frequency of the nausea and vomiting, which can provide clues to the possible causes and severity of the problem.

Choice B reason:

Asking the client about allergies or food intolerances is not directly related to the problem of nausea and vomiting. It might be useful to ask this question later in the assessment, but it is not the priority at this point. This question is more suitable for a comprehensive or initial assessment.

Choice C reason:

Asking the client to rate their pain on a scale of 0 to 10 is not relevant to the problem of nausea and vomiting. Pain is a different symptom that might or might not be associated with nausea and vomiting. This question is more suitable for a pain assessment.

Choice D reason:

Asking the client about their health goals is not related to the problem of nausea and vomiting. This question is more suitable for a wellness assessment or a health promotion intervention.

A. The size and depth of the ulcer. B. The presence of drainage or odor. C. The type and amount of pain medication administered. D. The client's nutritional status and intake. E. The client's level of mobility and activity.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason:

The size and depth of the ulcer are important indicators of the severity and healing progress of the wound. The nurse should measure the length, width, and depth of the ulcer using a ruler or a probe and document the findings. The nurse should also note the presence of any undermining or tunneling in the wound bed.

Choice B reason:

The presence of drainage or odor can signal infection or necrosis in the wound. The nurse should assess the amount, color, consistency, and odor of the drainage and document the findings. The nurse should also culture the wound if indicated and initiate appropriate wound care interventions.

Choice C reason:

The type and amount of pain medication administered are not directly related to the assessment of the pressure ulcer. Pain is a subjective experience that varies among individuals and situations. The nurse should assess the client's pain level using a valid pain scale and administer analgesics as prescribed, but this is not part of the ongoing assessment of the wound itself.

Choice D reason:

The client's nutritional status and intake are vital factors that affect wound healing. The nurse should assess the client's weight, body mass index, serum albumin, prealbumin, and transferrin levels, and dietary intake of protein, calories, vitamins, minerals, and fluids. The nurse should also provide nutritional supplements or consult a dietitian as needed to optimize the client's nutritional status.

Choice E reason:

The client's level of mobility and activity are also important factors that influence wound healing. The nurse should assess the client's ability to move, reposition, and ambulate independently or with assistance. The nurse should also implement measures to reduce pressure, shear, and friction on the wound site, such as using pressure-relieving devices, turning and repositioning the client frequently, and providing skin care.

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A nurse is conducting an initial assessment for a client who was admitted with pneumonia. Which of the following actions should the nurse take during this phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a problem-focused assessment for a client who reports nausea and vomiting. Which of the following statements should the nurse make to gather more information about the problem?

Correct Answer is A

Explanation

A nurse is performing an ongoing assessment for a client who has a pressure ulcer. Which of the following data should the nurse collect? (Select all that apply).

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is conducting a health promotion workshop for a group of clients who want to improve their physical activity levels. Which of the following questions should the nurse ask to assess their readiness for enhanced fitness?(Select all that apply.).

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