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 B

Explanation

A. "I will make exercise a part of my daily activities." This is a positive and correct statement. Regular exercise is an important component of a healthy lifestyle and should be encouraged.

B. "I should eat a diet high in fats but low in fiber." This statement is incorrect and indicates a misunderstanding of healthy dietary guidelines. A diet high in fats and low in fiber is not recommended for maintaining health and can lead to various health issues like obesity, heart disease, and digestive problems.

C. "I only have one glass of wine a day with dinner." This statement aligns with moderate alcohol consumption guidelines, which suggest that up to one glass of wine per day for women and two for men can be part of a healthy lifestyle.

D. "I will begin a smoking cessation program this week." This statement reflects a positive health choice. Quitting smoking is one of the most beneficial actions a person can take for their health, reducing risks for many diseases.

A. Ask the client to read a Snellen chart. B. Listen to the client's speech. C. Ask the client to clench his teeth. D. Ask the client to identify scented aromas.

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.

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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 educating a group of middle adults about health promotion. What statement by one of the participants indicates the need for additional education?

Correct Answer is B

Explanation

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

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