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 C

Explanation

Choice A reason: This is incorrect because placing soiled linens in the dirty linen receptacle can expose other clients and staﬀ to the hepatitis virus, which can be transmited through blood and body ﬂuids.

Choice B reason: This is incorrect because placing soiled linens on the ﬂoor can create a safety hazard and a potential source of infection for anyone who comes in contact with them.

Choice C reason: This is correct because placing soiled linens in a plastic bag that has the contamination symbol can prevent the spread of infection and alert the laundry department to handle them with caution.

Choice D reason: This is incorrect because placing soiled linens in the hazardous waste receptacle can waste resources and violate the regulations for disposing of hazardous materials.

A. "I can see you are worried.” B. “Don’t worry, you have nothing to feel guilty about.” C. "Everything possible is being done.” D. "Let me check if you can see your loved one.”

Correct Answer is A

Explanation

Choice A reason: “I can see you are worried.” is a therapeutic response by the PN to the family at this time. This response shows empathy, which is the ability to understand and share the feelings of another person. It also acknowledges and validates the family’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.

Choice B reason: “Don’t worry, you have nothing to feel guilty about.” is not a therapeutic response by the PN to the family at this time. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also implies that the family should feel guilty, and denies them the opportunity to explore their feelings or thoughts. Therefore, this choice is incorrect.

Choice C reason: “Everything possible is being done.” is not a therapeutic response by the PN to the family at this time. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also avoids addressing the family’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.

Choice D reason: “Let me check if you can see your loved one.” is not a therapeutic response by the PN to the family at this time. This response shows changing the subject, which is a communication technique that involves shifting the focus away from the other person’s feelings or situation. It also ignores or postpones the family’s emotional needs, and may make them feel unimportant or dismissed. 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

What should the nurse do with linens that have been soiled by a client with hepatitis?

Correct Answer is C

Explanation

Family members awaiting the outcome of a suicide atempt are tearful. Which response by the Practical Nurse (PN) is therapeutic to the family at this time? * Select one answer

Correct Answer is A

Explanation

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

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The Practical Nurse (PN) explains that the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication is to: