A nurse is developing a care plan for a client who has impaired mobility due to a stroke. Which of the following actions should the nurse take first when formulating a diagnostic statement?

Identify the client's health problems.

Cluster the assessment data.

Validate the data with the client.

Prioritize the health problems

Answer and Explanation

The Correct Answer is B

Choice A reason:

Identifying the client's health problems is not the first step in formulating a diagnostic statement. The nurse needs to gather and analyze the assessment data before identifying the health problems.

Choice B reason:

Clustering the assessment data is the first step in formulating a diagnostic statement. The nurse groups related data together to identify patterns and relationships that indicate a human response to health conditions or life processes.

Choice C reason:

Validating the data with the client is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then validate it with the client to ensure accuracy and completeness.

Choice D reason:

Prioritizing the health problems is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then identify the health problems before prioritizing them.

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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 nurse checks the client's identification bracelet and verifies allergies. B. The nurse measures the client's blood pressure in both arms and compares with previous readings. C. The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. D. The nurse reviews the most current evidence and guidelines for hypertension management. E. The nurse explains the purpose, procedure, and potential side effects of the intervention to the client.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason:

The nurse checks the client's identification bracelet and verifies allergies. This is an essential component of this skill because it ensures that the nurse is performing the intervention for the right client and avoids any potential adverse reactions or interactions due to allergies.

Choice B reason:

The nurse measures the client's blood pressure in both arms and compares with previous readings. This is not an essential component of this skill because it is not directly related to the intervention for hypertension. It is a part of the assessment process that should be done before planning the intervention.

Choice C reason:

The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. This is an essential component of this skill because it helps the nurse to identify any possible factors that may affect the client's blood pressure or the effectiveness of the intervention. Some medications or supplements may interact with the prescribed drugs or alter the blood pressure level.

Choice D reason:

The nurse reviews the most current evidence and guidelines for hypertension management. This is not an essential component of this skill because it is not specific to the client's situation or needs. It is a part of the planning process that should be done before implementing the intervention.

Choice E reason:

The nurse explains the purpose, procedure, and potential side effects of the intervention to the client. This is an essential component of this skill because it respects the client's autonomy and informed consent. It also helps the client to understand what to expect and how to cope with any possible complications or discomforts.

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A nurse is developing a care plan for a client who has impaired mobility due to a stroke. Which of the following actions should the nurse take first when formulating a diagnostic statement?

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 reassessing a client before performing an intervention for a client who has hypertension. Which of the following are essential components of this skill? (Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

A nurse is preparing a diagnostic statement for a client who has chronic obstructive pulmonary disease (COPD) and reports shortness of breath and fatigue with minimal exertion. Which of the following formats should the nurse use to write the statement?

A nurse is conducting an assessment on a client who has multiple sclerosis (MS). Which of the following data should the nurse collect? (Select all that apply.).

A nurse is planning care for a patient who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea at rest. Which of the following interventions should be included in the plan of care?(Select all that apply.).

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?

A nurse is documenting the data collected from an assessment of a client who has a urinary tract infection (UTI). Which of the following statements should the nurse use to record objective data?

Which of these is an example of a goal rather than an outcome?

Which of these are characteristics of a well-written outcome?(Select all that apply.)