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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pulse deficit refers to the difference between the apical and radial pulse, not a silence between sounds during blood pressure measurement.
B. Diastolic refers to the phase of the blood pressure cycle when the heart is at rest, not to a silent period.
C. An auscultatory gap is a period of silence between the systolic and diastolic sounds heard when taking blood pressure. It can be indicative of arterial stiffness or other vascular issues.
D. Widened pulse pressure refers to the difference between systolic and diastolic pressures, not a silence during auscultation.
Correct Answer is ["A","B","C","D"]
Explanation
A. A significant drop in blood pressure when standing (typically greater than 20 mm Hg systolic or 10 mm Hg diastolic) is a hallmark of orthostatic hypotension.
B. Dizziness upon standing is a classic symptom of orthostatic hypotension due to decreased blood flow to the brain.
C. Blurred vision can also result from decreased blood flow and is a common symptom of orthostatic hypotension.
D. Syncope (fainting) can occur as a result of orthostatic hypotension when the brain does not receive enough oxygenated blood due to the drop in blood pressure.
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