A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client?

Emergency

Time-lapse

Focused

Initial

Answer and Explanation

The Correct Answer is A

A. Emergency: This type of assessment is rapid and focuses on identifying and treating life-threatening conditions immediately, such as profuse bleeding from a stab wound.

B. Time-lapse: This assessment compares current client data to previous data to assess progress, which is not appropriate for an acute, life-threatening situation.

C. Focused: While this is a detailed assessment of a specific problem area, an emergency assessment is needed first for immediate threats to life.

D. Initial: This is a comprehensive assessment typically conducted when a client first enters a healthcare setting, but in an emergency, the focus shifts to immediate life-saving measures.

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Correct Answer is D

Explanation

A. "I will begin 48 hr before the client's discharge." Waiting until 48 hours before discharge does not provide enough time for thorough planning, education, or addressing potential needs after discharge.

B. "I will begin once the client's insurance company approves discharge coverage." Discharge planning should not depend solely on insurance approval. It needs to be proactive and begin earlier to ensure comprehensive planning and education.

C. "I will begin once the client's discharge order is written." Starting discharge planning only after the discharge order is written does not allow adequate time for preparation and may result in rushed or incomplete planning.

D. "I will begin upon the client's admission to the facility."Discharge planning should start at admission. Early planning ensures that all aspects of post-discharge care are considered and allows ample time for education, coordination, and addressing potential barriers to successful discharge.

A. Document "impaired oxygenation" on the nursing care plan. B. Auscultate the chest for breath sounds. C. Collaborate with the client to form goals. D. Apply supplemental oxygen by face mask as needed.

Correct Answer is B

Explanation

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

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A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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