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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: “Where do you hurt?” is not the best response to the PN’s observations. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows confrontation, which is a communication technique that involves challenging or opposing the other person’s statements or behaviors. It may make the client feel defensive, pressured, or misunderstood, and may discourage further communication. Therefore, this choice is incorrect.
Choice B reason: "I am glad you are feeling beter and have no discomfort.” is not the best response to the PN’s observations. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows inconsistency, which is a communication barrier that involves giving contradictory or conflicting messages. It may make the client feel confused, ignored, or invalidated, and may undermine the trust or rapport between the client and the PN. Therefore, this choice is incorrect.
Choice C reason: "What you are saying and what I am observing don’t seem to match.” is the best response to the PN’s observations. This response shows reflection, which is a communication technique that involves restating or paraphrasing what the client has said to show understanding and clarify meaning. It also shows congruence, which is a communication skill that involves using consistent verbal and nonverbal cues to reinforce the message and avoid confusion or misunderstanding. It helps the client to recognize and explore their own feelings or thoughts, and shows that the PN is atentive, respectful, and empathetic. Therefore, this choice is correct.
Choice D reason: "It makes me uncomfortable when you are not honest with me.” is not the best response to the PN’s observations. This response shows self-disclosure, which is a communication technique that involves sharing personal information or feelings with the other person. It also shows accusation, which is a communication barrier that involves blaming or criticizing the other person for their statements or behaviors. It may make the client feel
guilty, ashamed, or angry, and may damage the relationship or communication between the client and the PN. Therefore, this choice is incorrect.
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.
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