Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)
Maslow’s hierarchy of needs
A head-to-toe assessment
Subjective data collection
Review of systems
Correct Answer : B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
Choice A reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Long explanations can confuse and overwhelm the client, who may have difficulty processing and retaining information.
Choice B reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Asking one question at a time can help the client focus and respond more easily, without feeling pressured or frustrated.
Choice C reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Using short sentences can help the client understand and remember the message, without being distracted or confused by unnecessary words.
Choice D reason: This is incorrect because it shows that the PN is rude and disrespectful to the client’s hearing ability. Talking loudly can make the client feel annoyed or threatened, and may not improve communication if the client has hearing loss. The PN should talk in a normal tone and check for understanding.
Correct Answer is D
Explanation
Choice A reason: Counteract shyness in the client is not the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to establish rapport, show interest, or convey sincerity, but it may not necessarily counteract shyness in the client. In fact, some clients may feel uncomfortable, intimidated, or threatened by too much eye contact, especially if they are shy, anxious, or from a different cultural background. Therefore, this choice is incorrect.
Choice B reason: Keep the Practical Nurse’s atention on the conversation is not the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to keep the
Practical Nurse’s atention on the conversation, but it is not the main purpose or outcome of doing so. The main purpose or outcome of maintaining eye contact is to communicate with the other person effectively and respectfully, not to focus on oneself or one’s own behavior. Therefore, this choice is incorrect.
Choice C reason: Assess if the client is involved in the conversation is not the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to assess if the client is involved in the conversation, but it is not the only or most reliable way of doing so. The Practical Nurse should also pay atention to other verbal and nonverbal cues from the client, such as their tone of voice, facial expressions, body language, or feedback. Therefore, this choice is incorrect.
Choice D reason: Indicate continuous focused atention is the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can indicate continuous focused atention, which means that the Practical Nurse is listening actively, understanding empathetically, and responding appropriately to the client’s message. It can also show respect, interest, or sincerity to the client, and enhance rapport and trust between them. Therefore, this choice is correct.
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