Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Ongoing assessment

Focused assessment

Emergency assessment

Comprehensive assessment

Answer and Explanation

The Correct Answer is A

A. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

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Correct Answer is C

Explanation

A. Lithotomy: The lithotomy position is primarily used for gynecological exams and procedures, where the client is lying on their back with legs elevated and supported. It is not appropriate for breast examination.

B. Sims: The Sims position, where the client is lying on their side with one knee bent, is typically used for rectal exams and certain types of enemas. It is not suitable for breast examination.

C. Supine: The supine position, where the client lies flat on their back, is the most appropriate for breast examination. This position allows for better palpation and inspection of the breasts and facilitates a thorough examination.

D. Prone: The prone position involves lying face down. This position does not provide access to the breasts and is not used for breast examination.

A. "I will begin 48 hr before the client's discharge." B. "I will begin once the client's insurance company approves discharge coverage." C. "I will begin once the client's discharge order is written." D. "I will begin upon the client's admission to the facility."

Correct Answer is D

Explanation

A. "I will begin 48 hr before the client's discharge." Waiting until 48 hours before discharge does not provide enough time for thorough planning, education, or addressing potential needs after discharge.

B. "I will begin once the client's insurance company approves discharge coverage." Discharge planning should not depend solely on insurance approval. It needs to be proactive and begin earlier to ensure comprehensive planning and education.

C. "I will begin once the client's discharge order is written." Starting discharge planning only after the discharge order is written does not allow adequate time for preparation and may result in rushed or incomplete planning.

D. "I will begin upon the client's admission to the facility."Discharge planning should start at admission. Early planning ensures that all aspects of post-discharge care are considered and allows ample time for education, coordination, and addressing potential barriers to successful discharge.

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Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to examine the breasts of a client. In what position should the nurse place the client?

Correct Answer is C

Explanation

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

Correct Answer is D

Explanation

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