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. 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

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

Correct Answer is C

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 female client who is experiencing disordered thinking about food being poisoned is admited to the mental health unit. The nurse should use which communication technique to encourage the client to eat dinner? Select one answer

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When a female client preparing for surgery suddenly bursts into tears, the nurse should take which of the following actions? · Select one answer

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