A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

A patient who is scheduled for a routine follow-up visit for hypertension management.

A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene.

A patient who is recovering from an appendectomy and is asking about discharge instructions.

A patient who is complaining of sudden onset chest pain and shortness of breath.

Answer: D

Answer and Explanation

The Correct Answer is D

A. A patient who is scheduled for a routine follow-up visit for hypertension management. This is incorrect because this patient is stable and does not require immediate assessment. Routine follow-ups do not take priority over acute conditions.

B. A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene. This is incorrect because while personal hygiene is important, it is not urgent or life-threatening.

C. A patient who is recovering from an appendectomy and is asking about discharge instructions. This is incorrect because discharge teaching is important but can be scheduled later in the shift when more urgent needs have been addressed.

D. A patient who is complaining of sudden onset chest pain and shortness of breath. This is correct because sudden onset chest pain and shortness of breath can indicate a life-threatening condition such as myocardial infarction or pulmonary embolism. The nurse must immediately assess this patient to determine the cause and initiate emergency interventions if necessary.

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Correct Answer is C

Explanation

A. This is a closed-ended question that leads to a simple "yes" or "no" response, limiting the amount of information the nurse gathers.

B. While this is important information, it is not an appropriate opening question for a full nursing assessment, as it does not encourage the patient to share their primary concern.

C. This open-ended question allows the patient to provide a detailed narrative, helping the nurse gather a comprehensive history.

D. This is a closed-ended question that focuses only on pain rather than encouraging the patient to share their full reason for seeking care.

A. As written, the diagnosis is too complex. B. The staff nurse is being judgmental. C. The diagnosis is legally questionable. D. There is deficiency of supportive data.

Correct Answer is B

Explanation

A. The diagnosis is not necessarily complex.

B. Nursing diagnoses should be objective and free from judgment. "Laziness" is subjective and inappropriate.

C. No legal issue is present, but professionalism is lacking.

D. The issue is more about the judgmental phrasing than missing data.

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A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

Correct Answer is C

Explanation

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

Correct Answer is B

Explanation

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

When should a nurse perform an ongoing assessment during a patient's hospital stay?

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A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?