The assessment phase of the nursing process refers to the phase when data collection occurs. Which methods does the nurse use to collect data? (Select all that apply.)
Observing client behavior
Reviewing diagnostic testing results
Interviewing the client and significant others
Performing physical assessment
Interpreting client behaviors
Correct Answer : A,B,C,D
Choice A rationale: Observation is a method of data collection involving the use of one’s senses to notice the aspects of a client such as their appearance, expressions, and actions.
Choice B rationale: Reviewing diagnostic testing results is a method of collecting data that involves the examination of the findings of laboratory tests, imaging studies, and other procedures. These findings provide objective information about the client's physiological functioning.
Choice C rationale: client interview is a method of data collection involving asking them questions and listening to their responses. This method helps the nurse to obtain subjective data about the client's health history, current problems, expectations, values, and beliefs.
Choice D rationale: Performing physical assessment is a method of collecting data that involves using inspection, palpation, percussion, and auscultation to examine the different body systems of the client. This provides objective information about the patient’s condition.
Choice E rationale: this is incorrect since Interpreting client behaviors is not a method of collecting data but is instead a data analysis method.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: providing false reassurances invalidates the client’s feelings and concerns thus making them feel that the nurse is not trustworthy or empathetic. This may hinder the development of a therapeutic relationship.
Choice B rationale: the use of open-ended questions is appropriate since it allows the client to freely express their thoughts and feelings without being limited by the yes or no answers.
Choice C rationale: active listening involves paying attention to the client’s verbal and non-verbal cues and clarifying any possible misunderstandings.
Choice D rationale: silence is crucial since it enables the client to reflect on their thoughts and to process their emotions. Furthermore, it is a form of respect for the client’s feelings.
Correct Answer is A
Explanation
Choice A rationale: Axis 3 is used in the documentation of conditions, for instance, asthma, hypertension, and diabetes mellitus among others which are known to have effects on an individual’s mental health.
Choice B rationale: Axis 2 is used in the documentation of conditions affecting a client’s functioning such as personality disorders and mental retardation.
Choice C rationale: Axis 4 is used in the documentation of environmental and psychosocial issues contributing to a patient’s stress such as financial and family stressors.
Choice D rationale: Axis 1 is used to document clinical disorders that are the primary focus of management such as schizophrenia, major depressive disorder, and bipolar disorder among others.
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