It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

the beginning of each shift.

admission to the unit.

discharge.

the patient's wakening in the morning.

Answer and Explanation

The Correct Answer is A

A.   Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B.   While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C.   At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D.   While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.

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Correct Answer is D

Explanation

A. A score of 7 would indicate a much lower level of consciousness and require urgent intervention.
B. A score of 12 would indicate some level of impairment, with the patient not fully alert or responsive.
C. A score of 10 would indicate some level of impairment, with the patient not fully alert or responsive.
D. A score of 15 on the Glasgow Coma Scale indicates full consciousness and normal neurological function. It is the highest possible score, reflecting a patient who is awake, aware, and able to follow commands.

A. auscultate for bowel sounds once a shift. B. auscultate lung sounds at the beginning of a shift. C. monitor for skin turgor every shift. D. monitor peripheral pulses once a shift.

Correct Answer is B

Explanation

A. Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B. Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C. Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D. Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

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It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

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Correct Answer is B

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