A nurse is performing an initial assessment on a client who was admitted for pneumonia. Which of the following actions should the nurse take?

Compare the client's vital signs with the previous ones.

Ask the client about their medical history and current medications.

Perform a head-to-toe physical examination of the client.

Evaluate the effectiveness of the prescribed antibiotics.

Answer and Explanation

The Correct Answer is B

Choice A :

Comparing the client's vital signs with the previous ones is not the first action the nurse should take during an initial assessment. This is a part of an ongoing or focused assessment that monitors the client's response to treatment and identifies any changes in their condition.

Choice B :

Asking the client about their medical history and current medications is the correct action the nurse should take during an initial assessment. This is a part of collecting subjective data from the client that can provide valuable information about their health status, risk factors, allergies, preferences, and needs. This can help the nurse to identify any potential problems or complications related to the client's pneumonia and plan appropriate interventions.

Choice C :

Performing a head-to-toe physical examination of the client is not the first action the nurse should take during an initial assessment. This is a part of collecting objective data from the client that involves inspecting, palpating, percussing, and auscultating various body systems. However, before performing a physical examination, the nurse should obtain consent from the client, explain the purpose and procedure, and ensure privacy and comfort.

Choice D:

Evaluating the effectiveness of the prescribed antibiotics is not the first action the nurse should take during an initial assessment. This is a part of the evaluation phase of the nursing process that involves comparing the client's outcomes with the expected outcomes and modifying the plan of care as needed. However, before evaluating the effectiveness of any intervention, the nurse should first assess the client's baseline data and implement the intervention according to the plan of care.

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Correct Answer is B

Explanation

Choice A reason:.

Objective data is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. For example, vital signs, physical examination findings, and laboratory results are objective data. The client's report of feeling thirsty and hungry is not something that the nurse can observe directly, so it is not objective data.

Choice B reason:.

Subjective data is information obtained from the patient and/or family members and offers important cues from their perspectives. For example, the patient's pain level, feelings, beliefs, and preferences are subjective data. The client's report of feeling thirsty and hungry is something that only the client can describe, so it is subjective data. This is the correct answer.

Choice C reason:.

Primary data is information provided directly by the patient. For example, the patient's history, symptoms, and concerns are primary data. The client's report of feeling thirsty and hungry is primary data, but this is not the best answer because it does not specify whether it is subjective or objective. Primary data can be either subjective or objective depending on the source.

Choice D reason:.

Secondary data is information collected from a family member, chart, or other sources. For example, the patient's previous records, family history, and test results are secondary data. The client's report of feeling thirsty and hungry is not secondary data because it comes from the client directly, not from another source.

A. To determine the severity and location of the pain. B. To establish a baseline for evaluating interventions. C. To assess the client's coping skills and anxiety level. D. To identify any factors that aggravate or relieve the pain.

Correct Answer is B

Explanation

Choice A :

To determine the severity and location of the pain. This is not the best answer because the nurse already knows that the client is experiencing chest pain and shortness of breath, which are signs of a possible cardiac problem. The nurse should also ask about the quality, radiation, and aggravating or relieving factors of the pain, not just the severity and location.

Choice B:

To establish a baseline for evaluating interventions. This is the best answer because the nurse needs to know how severe the pain is before administering any medication or treatment, and then reassess the pain after the intervention to see if it was effective. The pain scale is a useful tool to measure the intensity of pain and compare it over time.

Choice C:

To assess the client's coping skills and anxiety level. This is not the best answer because the nurse should focus on relieving the pain first, as it is an emergency situation. The nurse can assess the client's coping skills and anxiety level later, when the pain is under control.

Choice D:

To identify any factors that aggravate or relieve the pain. This is not the best answer because the nurse should ask this question along with other questions about the pain characteristics, not as a single question. The nurse should also prioritize relieving the pain rather than identifying factors that may or may not affect it.

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