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

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.

Choice A reason:.

Gordon's functional health patterns is a framework that categorizes the data into functional health patterns, such as activity-exercise, nutrition-metabolism, and elimination. This framework was developed by Marjory Gordon in 1987 and is widely used by nurses to assess the health status of individuals, families, and communities.

Choice B reason:.

Maslow's hierarchy of needs is a motivational theory in psychology that proposes a five-tier model of human needs, often depicted as a pyramid. The needs are physiological, safety, love and belonging, esteem, and self-actualization. This theory is not a framework for organizing data collected from an assessment of a client.

Choice C reason:.

Orem's self-care deficit theory is a nursing theory that states that people have an innate ability to perform self-care activities that maintain their health and well-being. The theory consists of three related theories: the theory of self-care, the theory of self-care deficit, and the theory of nursing system. This theory is not a framework for organizing data collected from an assessment of a client.

Choice D reason:.

Roy's adaptation model is a nursing theory that views the person as a bio-psycho-social being who is constantly interacting with a changing environment. The theory focuses on how the person adapts to stimuli through four adaptive modes: physiological-physical, self-concept-group identity, role function, and interdependence. This theory is not a framework for organizing data collected from.