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. Testing visual acuity: This assesses cranial nerve II (Optic nerve).

B. Observing for facial symmetry: This assesses cranial nerve VII (Facial nerve).

C. Eliciting the gag reflex: This assesses cranial nerves IX and X (Glossopharyngeal and Vagus nerves).

D. Checking the pupillary response to light: This assesses cranial nerve III (Oculomotor nerve), which controls pupil constriction and eye movements.

A. Covert B. Subjective C. Objective D. Symptomatic

Correct Answer is C

Explanation

A. Covert: Covert data refers to information that is hidden, subjective, or not immediately observable, such as symptoms reported by the client. Voided volume is measurable and observable, so it is not covert.

B. Subjective: Subjective data is information reported by the client, such as feelings, perceptions, or symptoms. Since the urine output is a measurable and observable fact, it is not subjective.

C. Objective: Objective data is factual, measurable, and observable. The voided volume of 475 ml is a precise, quantifiable measurement, making it objective data.

D. Symptomatic: Symptomatic data pertains to symptoms experienced by the client, which are typically subjective. The documented urine output is a specific, quantifiable measurement and not a symptom.

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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

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is D

Explanation

At the end of the shift, the nurse documents that the client has voided 475 ml during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Correct Answer is C

Explanation

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