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. Sheepskin heel pad B. Abduction pillow C. Footboard D. Trochanter roll

Correct Answer is C

Explanation

A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.

B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.

C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.

D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.

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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

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?

Correct Answer is C

Explanation

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