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 A

Explanation

A. Ask the client to read a Snellen chart: Cranial nerve II (Optic nerve) is responsible for vision. Assessing the client's ability to read a Snellen chart tests visual acuity, which is a function of cranial nerve II.

B. Listen to the client's speech: This assesses cranial nerves V (Trigeminal) and VII (Facial), which are involved in speech and facial sensation.

C. Ask the client to clench his teeth: This assesses cranial nerve V (Trigeminal), which controls jaw movement and sensation.

D. Ask the client to identify scented aromas: This assesses cranial nerve I (Olfactory), which is responsible for the sense of smell.

A. Increased subcutaneous fat B. Increased skin turgor and moisture C. Decreased bone density D. The skin is more elastic E. Muscle mass gradually decreases F. Decreased auditory acuity

Correct Answer is ["A","C","E","F"]

Explanation

A. Increased subcutaneous fat: Middle adulthood often sees an increase in fat deposits, particularly around the abdomen, due to changes in metabolism and hormonal shifts.

B. Increased skin turgor and moisture: Incorrect. Aging typically leads to decreased skin turgor and moisture, causing the skin to become drier and less elastic.

C. Decreased bone density: Bone density generally decreases due to reduced bone remodeling, increasing the risk of fractures and osteoporosis.

D. The skin is more elastic: Incorrect. Skin elasticity usually decreases with age, resulting in wrinkles and sagging.

E. Muscle mass gradually decreases: Muscle mass tends to decline with age, a condition known as sarcopenia, leading to reduced strength and physical capability.

F. Decreased auditory acuity: Hearing loss, particularly high-frequency hearing loss, is common as people age due to changes in the inner ear and other auditory structures

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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 assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Correct Answer is A

Explanation

Which of the following are physical changes that occur in middle adulthood? Select all that apply.

Correct Answer is ["A","C","E","F"]

Explanation

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

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

A nurse is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview?

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A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

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