During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

Select one answer

Symptoms

Urinary retention

Signs of ﬂuid overload

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct because symptoms are subjective or objective manifestations of a health problem that are perceived or reported by the client.

Choice B reason: This is incorrect because urinary retention is a specific condition that involves the inability to empty the bladder completely, which is not related to the data presented.

Choice C reason: This is incorrect because signs of ﬂuid overload are opposite to the data presented, such as edema, weight gain, crackles in the lungs, and distended neck veins.

Choice D reason: This is incorrect because data clustering is a process of grouping related data together to identify paterns and potential problems, not a type of data itself.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect because it shows that the PN is not using a technique that encourages the client to express feelings and thoughts. A closed inquiry is a question that can be answered with a yes or no, or a short factual response.

Choice B reason: This is correct because it shows that the PN is using a technique that encourages the client to express feelings and thoughts. An open-ended question is a question that requires more than a yes or no, or a short factual response and invites the client to elaborate.

Choice C reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. Minimal encouraging is a verbal or nonverbal response that shows interest and attention and prompts the client to continue talking.

Choice D reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. A restating is a verbal response that repeats the main idea or keywords of the client’s message and confirms understanding.

A. Maslow’s hierarchy of needs B. A head-to-toe assessment C. Subjective data collection D. Review of systems

Correct Answer is ["B"]

Explanation

Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.

Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.

Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.

Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.

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During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

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Naxlex Comprehensive Predictor Exams

The young client says, “I’m really stressed out about this pregnancy.” When the Practical Nurse (PN) responds, “What about this pregnancy worries you?”, he or she is using the technique of:

Correct Answer is B

Explanation

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Correct Answer is ["B"]

Explanation

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