Introduction to Patient Assessment and Documentation

A nurse is assessing a client who has been admitted with chest pain.

Which of the following findings should the nurse report to the provider immediately?

A nurse is documenting the findings of a head-to-toe assessment on a newly admitted client.

Which of the following information should the nurse include in the documentation?

A nurse is performing a physical assessment on a client who has abdominal pain.

Which of the following techniques should the nurse use to assess the abdomen?

A nurse is reviewing the medical record of a client who has been diagnosed with pneumonia.

Which of the following data should the nurse use to evaluate the effectiveness of the treatment plan?

A nurse is preparing to perform a neurological assessment on a client who has a head injury.

Which of the following tools should the nurse use to assess the client's level of consciousness?

A nurse is conducting a health history interview with a client who has a chronic cough.

Which of the following questions should the nurse ask to elicit relevant information about the cough?