In what patient situations would a focused assessment be best to perform?
preparing the client for discharge
On initial evaluation by the home health nurse
reassessing a client for pain after giving pain medication
checking skin assessment on a patient with a medical device in place
The Correct Answer is C
A. Preparing the client for discharge: Discharge preparation typically requires a comprehensive assessment to ensure all aspects of the client’s health and care needs are addressed.
B. On initial evaluation by the home health nurse: The initial evaluation requires a comprehensive assessment to establish a baseline for the client's overall condition and care plan.
C. Reassessing a client for pain after giving pain medication: A focused assessment targets a specific problem area, such as evaluating pain levels after an intervention.
D. Checking skin assessment on a patient with a medical device in place: This is an example of a focused assessment, concentrating on the skin integrity around the medical device.
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Related Questions
Correct Answer is C
Explanation
A. Vomiting: Vomiting is objective data because it can be observed and measured by the nurse.
B. Auscultation of heart murmur: This is objective data obtained through physical examination techniques.
C. Client's complaint of nausea: Subjective data is information reported by the client about their experience, feelings, or symptoms, which cannot be directly observed by others.
D. Blood pressure reading: This is objective data obtained through measurement.
Correct Answer is A
Explanation
A. The nurse determines the client’s readiness to learn: Assessing the client's readiness to learn is part of the assessment phase of the teaching plan. It involves evaluating the client’s emotional and cognitive state to ensure they are prepared to absorb new information.
B. The nurse discusses types of food that the client needs to avoid: This is part of the teaching or implementation phase, not the assessment phase.
C. The nurse describes which supplies would be needed: Describing necessary supplies is also part of the teaching or implementation phase.
D. Ask the client to demonstrate emptying of the colostomy bag: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the task taught.
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