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
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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Related Questions
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.
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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