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 C
Explanation
A. Lithotomy: The lithotomy position is primarily used for gynecological exams and procedures, where the client is lying on their back with legs elevated and supported. It is not appropriate for breast examination.
B. Sims: The Sims position, where the client is lying on their side with one knee bent, is typically used for rectal exams and certain types of enemas. It is not suitable for breast examination.
C. Supine: The supine position, where the client lies flat on their back, is the most appropriate for breast examination. This position allows for better palpation and inspection of the breasts and facilitates a thorough examination.
D. Prone: The prone position involves lying face down. This position does not provide access to the breasts and is not used for breast examination.
Correct Answer is A
Explanation
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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