A nurse is caring for a newly admitted client. Which should the nurse include in the assessment phase of the nursing process?

Identify the needed nursing actions to address the client's health problem.

Interview the client about current and past health history.

Measure the success of the care goals.

Develop the expected outcome with the client.

Answer and Explanation

The Correct Answer is B

A. Identify the needed nursing actions to address the client's health problem: Planning and determining interventions occur in the planning phase, not during assessment. Assessment focuses on data collection rather than action implementation.

B. Interview the client about current and past health history: Collecting subjective and objective information through interviews, observation, and examination is the core of the assessment phase. This information forms the foundation for identifying problems and planning care.

C. Measure the success of the care goals: Evaluating whether goals have been met is part of the evaluation phase. It occurs after interventions have been implemented and outcomes are assessed.

D. Develop the expected outcome with the client: Establishing expected outcomes is part of the planning phase. It follows assessment and involves collaboration with the client to determine realistic and measurable goals.

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Correct Answer is A

Explanation

A. A client who is reporting a severe headache and new vision changes: Sudden severe headache with vision changes may indicate a potentially life-threatening condition such as a stroke, aneurysm, or increased intracranial pressure. This client requires an immediate emergency assessment to prevent serious complications.

B. A client who requires assistance when transferring to the exam table: Needing help with transfers is important for safety but does not indicate an urgent medical condition. This task can be addressed after more critical clients are assessed.

C. A client who requires a follow-up physical for their medication refill: Routine follow-up for prescription refills is non-urgent and can safely be scheduled after emergency or acute cases are addressed.

D. A client who is reporting minor swelling and pain in their left foot: Minor swelling and pain are usually non-life-threatening. While assessment is necessary, it does not require immediate emergency evaluation compared to acute neurological or vision changes.

A. "Is it correct that you are here due to leg pain?" B. "Do you have any family or friends with you?" C. "What brings you to the hospital today?" D. "What medications have you taken recently?"

Correct Answer is C

Explanation

A. "Is it correct that you are here due to leg pain?": This is a closed-ended question that only confirms a specific detail. It limits the client’s opportunity to provide additional information or context about their condition.

B. "Do you have any family or friends with you?": This question addresses support systems, which is useful but does not elicit comprehensive information about the client’s health concerns or reason for seeking care.

C. "What brings you to the hospital today?": This open-ended question encourages the client to describe their primary concerns in their own words. It allows the nurse to gather a broad and detailed understanding of the client’s symptoms, history, and perspective.

D. "What medications have you taken recently?": This question provides specific information about pharmacological history but does not allow the client to share additional details about their current condition or health concerns.

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A nurse is caring for a newly admitted client. Which should the nurse include in the assessment phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of clients. Which client should the nurse plan to complete an emergency assessment on?

Correct Answer is A

Explanation

The nurse conducts an initial interview with a client. Which question should the nurse ask to elicit the most information?

Correct Answer is C

Explanation

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