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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Assessment: Assessment is the initial data collection phase before intervention.
B. Evaluation: Evaluation involves determining the effectiveness of an intervention. Checking blood sugar after administering insulin is evaluating the effectiveness of the insulin.
C. Planning: Planning involves setting goals and deciding on interventions, not the follow-up.
D. Implementation: Implementation involves carrying out the planned interventions, such as administering insulin, not checking the results.

A. "The vital signs are stable" B. "The client has a history of high blood pressure" C. "The client is disoriented. Pupils are slow to respond to light." D. "The client should be seen by a neurologist."

Correct Answer is C

Explanation

A. "The vital signs are stable." This statement belongs in the Assessment (A) step, as it provides information about the client’s current clinical condition.
B. "The client has a history of high blood pressure." This statement belongs in the Background (B) step, providing relevant medical history.
C. "The client is disoriented. Pupils are slow to respond to light." The S (Situation) step involves stating the immediate problem or reason for the communication. Describing the client's disorientation and pupil response directly addresses the current issue that prompted the call.
D. "The client should be seen by a neurologist." This statement belongs in the Recommendation (R) step, suggesting the next course of action.

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In what patient situations would a focused assessment be best to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing is checking the client's blood sugar after administering insulin to a diabetic client. Which part of the nursing process is being fulfilled?

Correct Answer is B

Explanation

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the S step?

Correct Answer is C

Explanation

A nurse is vaccinating n child with the varicella vaccine. The nurse is implementing what level of preventative care?

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A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?

A nurse at the clinic is teaching a client with diabetes the importance of monitoring their blood sugar. The nurse is implementing what level of preventative care?

An 84-year-old cognitively-impaired gentleman is admitted from a skilled nursing facility to your acute care facility for increasing agitation and combativeness in the last few days. Which of the following is an example of effective communication with this client?