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. Older Adult: Scoliosis screening is typically performed during adolescence, not in older adults. Older adults are more likely to be screened for other conditions such as osteoporosis.
B. Pre-adolescent/adolescent: Scoliosis screening is most commonly conducted during preadolescence and adolescence, typically around 10-15 years of age, when growth spurts occur, and the spine is most susceptible to curvature.
C. Toddler/Preschooler: Scoliosis is rarely screened in toddlers or preschoolers. This age group focuses more on developmental milestones and immunizations.
D. Infant: Scoliosis is not typically screened in infants. Screening for spinal curvature is more relevant during the rapid growth periods of adolescence.
Correct Answer is D
Explanation
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
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