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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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.
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