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

Answer and Explanation

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.

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Correct Answer is D

Explanation

D) “I understand that you would like some ice cream, but I need you to be more respectful when you ask me for something.” This is an assertive response because it acknowledges the patient’s request, expresses the nurse’s feelings, and sets a clear boundary for acceptable behavior. Assertiveness is the ability to communicate one’s needs, opinions, and feelings in a respectful and confident manner.

“You are hungry and want a snack. I can do that in 10 minutes when I finish my rounds.” is incorrect. This is a passive response because it does not address the patient’s rudeness or assert the nurse’s rights. Passive communication is the tendency to avoid conﬂict, suppress one’s feelings, and comply with others’ demands.

“Maybe I can get one of the aides to bring you something in a while.” is incorrect. This is an evasive response because it does not commit to fulfilling the patient’s request or confronting the patient’s attitude. Evasive communication is the tendency to avoid responsibility, give vague answers, and shift blame to others.

“Call the nursing station and ask them to have the kitchen bring whatever you want.” is incorrect. This is an aggressive response because it rejects the patient’s request, shows irritation, and implies that the nurse does not care about the patient’s needs. Aggressive communication is the tendency to dominate, criticize, and blame others.

A. Identify outcomes B. Planning C. A “risk for” nursing diagnosis D. Implementation

Correct Answer is ["A"]

Explanation

Choice A reason: Identify outcomes is a step of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. Therefore, this choice is correct.

Choice B reason: Planning is a step of the nursing process that involves designing a plan of care that outlines the interventions and activities that will help the client achieve the desired outcomes. The plan of care is also developed in collaboration with the client and the nurse, and it reﬂects the client’s priorities and resources. Therefore, this choice is correct.

Choice C reason: A “risk for” nursing diagnosis is a type of nursing diagnosis that identifies a potential problem or complication that the client may develop if preventive measures are not taken. It is not a step of the nursing process,

but rather a component of the assessment step, which involves collecting and analyzing data about the client’s health status. Therefore, this choice is incorrect.

Choice D reason: Implementation is a step of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. It is not a step where the goals are developed, but rather where they are executed. Therefore, this choice is incorrect.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

Correct Answer is D

Explanation

In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

Correct Answer is ["A"]

Explanation

A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client’s leg is pain free, without redness or edema. The nurse’s actions reﬂect which phase of the nursing process? Select one answer

The nurse preceptor is instructing the new nurse on appropriate communication techniques. The new nurse indicates a need for further teaching on using assertive communication, if she does which of the following when communicating with patients? Select one answer

The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

Although the client denies pain, the Practical Nurse (PN) observes the client is breathing rapidly with clenched fists and is grimacing. The PN’s best response to his observations would be: * Select one answer

A nurse is caring for a client who is hearing-impaired and takes which approach to best facilitate communication? (Select all that apply)

A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)