A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Set client-centered, measurable and realistic goals.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Collect and organize client data.
The Correct Answer is D
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will make exercise a part of my daily activities." This is a positive and correct statement. Regular exercise is an important component of a healthy lifestyle and should be encouraged.
B. "I should eat a diet high in fats but low in fiber." This statement is incorrect and indicates a misunderstanding of healthy dietary guidelines. A diet high in fats and low in fiber is not recommended for maintaining health and can lead to various health issues like obesity, heart disease, and digestive problems.
C. "I only have one glass of wine a day with dinner." This statement aligns with moderate alcohol consumption guidelines, which suggest that up to one glass of wine per day for women and two for men can be part of a healthy lifestyle.
D. "I will begin a smoking cessation program this week." This statement reflects a positive health choice. Quitting smoking is one of the most beneficial actions a person can take for their health, reducing risks for many diseases.
Correct Answer is A
Explanation
A. Inspection: Inspection is always the first step in any physical examination, including abdominal assessments. It allows the nurse to visually assess the abdomen for distension, asymmetry, discoloration, or other abnormalities.
B. Percussion: Percussion is performed after inspection and auscultation. It helps assess the density of abdominal contents but should not be the first step.
C. Palpation: Palpation is performed last in an abdominal exam to avoid altering bowel sounds and causing discomfort. It should be done after inspection, auscultation, and percussion.
D. Auscultation: Auscultation is typically the second step after inspection to listen for bowel sounds before palpation and percussion, which might alter them.
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