The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Consult clinical resources explaining the client's diagnosis

Perform a mini overview of the client's body systems.

Obtain and organize materials you will need for the assessment.

Review client's medical record

Answer and Explanation

The Correct Answer is D

A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.

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Correct Answer is D

Explanation

A. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.

A. Understanding of the referral process. B. Recognition of the client's medical prognosis. C. Drawing inferences about the client. D. Knowledge of anatomy and physiology.

Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

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The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

Correct Answer is D

Explanation

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Correct Answer is C

Explanation

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?