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 ["B"]

Explanation

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coﬀee. The nurse should not delay providing care for a client who may have suﬀered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coﬀee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coﬀee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coﬀee.

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)

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Naxlex Comprehensive Predictor Exams

A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

Correct Answer is ["B"]

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

The young client says, “I’m really stressed out about this pregnancy.” When the Practical Nurse (PN) responds, “What about this pregnancy worries you?”, he or she is using the technique of:

A client of the Islamic faith refuses to eat a hot dog on his tray because he is afraid that it may contain pork products. Which of the following is the best response by the Practical Nurse (PN)?

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

Which of the following types of posture is best for the nurse to use when communicating with the patient? (Select all that apply)

A client with chronic renal failure is admited with a heart rate of 122 beats/minute; a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Select one answer

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

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)