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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Cognitive dysfunction: This is a broad term that includes various types of cognitive impairment.

B. Alzheimer's disease: This is a specific type of dementia, but it doesn’t specifically describe the timing of confusion.

C. Sundowning syndrome: This term describes increased confusion and agitation in the late afternoon and evening. It’s commonly seen in individuals with dementia.

D. Night-time confusion: This is a general term and doesn't specifically relate to the characteristic pattern of sundowning.

A. Ask the client to read a Snellen chart. B. Listen to the client's speech. C. Ask the client to clench his teeth. D. Ask the client to identify scented aromas.

Correct Answer is A

Explanation

A. Ask the client to read a Snellen chart: Cranial nerve II (Optic nerve) is responsible for vision. Assessing the client's ability to read a Snellen chart tests visual acuity, which is a function of cranial nerve II.

B. Listen to the client's speech: This assesses cranial nerves V (Trigeminal) and VII (Facial), which are involved in speech and facial sensation.

C. Ask the client to clench his teeth: This assesses cranial nerve V (Trigeminal), which controls jaw movement and sensation.

D. Ask the client to identify scented aromas: This assesses cranial nerve I (Olfactory), which is responsible for the sense of smell.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The adult child of an older adult calls the nurse practitioner to report that the parent is becoming very confused after dark. What is this type of confusion named?

Correct Answer is C

Explanation

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Correct Answer is A

Explanation

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