A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the basis for:
a complete physical examination
a medical assessment
writing nursing orders
an individualized plan of care
The Correct Answer is D
A. A complete physical examination – While a physical examination is part of data collection, the primary goal of a nursing assessment is to guide nursing care rather than conduct a full medical examination.
B. A medical assessment – Medical assessments are conducted by physicians to diagnose diseases, while nursing assessments focus on holistic patient care.
C. Writing nursing orders – Nursing orders are based on the care plan but do not encompass the entire purpose of the assessment.
D. An individualized plan of care – The primary purpose of a nursing assessment is to collect data to create a care plan tailored to the patient's specific needs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Percussion – Percussion involves tapping the body to assess underlying structures, not feeling for texture or consistency.
B. Auscultation – Auscultation is listening to body sounds (e.g., heart, lungs, and bowels) using a stethoscope, not feeling structures.
C. Inspection – Inspection is visual observation, not a tactile assessment.
D. Palpation – Palpation involves using the hands to assess the texture, size, consistency, and location of body structures, such as organs or lymph nodes.
Correct Answer is A
Explanation
A. Prevent distortion of bowel sounds. – Palpation can stimulate peristalsis and alter bowel sounds, leading to inaccurate assessment findings.
B. Prevent distortion of vascular sounds. – While palpation might affect vascular sounds slightly, this is not the primary concern when assessing the abdomen.
C. Determine any areas of tenderness or pain. – While assessing for tenderness is important, auscultation precedes palpation primarily to avoid altering bowel sounds.
D. Allow the patient to relax and be comfortable. – While relaxation is beneficial, the sequence of assessment is based on maintaining accuracy in findings rather than patient comfort.
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