A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

“You are hungry and want a snack. I can do that in 10 minutes when I finish my rounds.”

“Maybe I can get one of the aides to bring you something in a while.”

“Call the nursing station and ask them to have the kitchen bring whatever you want.”

“I understand that you would like some ice cream, but I need you to be more respectful when you ask me for something.”

Answer and Explanation

The Correct Answer is D

D) “I understand that you would like some ice cream, but I need you to be more respectful when you ask me for something.” This is an assertive response because it acknowledges the patient’s request, expresses the nurse’s feelings, and sets a clear boundary for acceptable behavior. Assertiveness is the ability to communicate one’s needs, opinions, and feelings in a respectful and confident manner.

“You are hungry and want a snack. I can do that in 10 minutes when I finish my rounds.” is incorrect. This is a passive response because it does not address the patient’s rudeness or assert the nurse’s rights. Passive communication is the tendency to avoid conﬂict, suppress one’s feelings, and comply with others’ demands.

“Maybe I can get one of the aides to bring you something in a while.” is incorrect. This is an evasive response because it does not commit to fulfilling the patient’s request or confronting the patient’s attitude. Evasive communication is the tendency to avoid responsibility, give vague answers, and shift blame to others.

“Call the nursing station and ask them to have the kitchen bring whatever you want.” is incorrect. This is an aggressive response because it rejects the patient’s request, shows irritation, and implies that the nurse does not care about the patient’s needs. Aggressive communication is the tendency to dominate, criticize, and blame others.

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Correct Answer is ["B"]

Explanation

Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.

Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.

Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.

Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.

A. Goals that the patient and his family ask the nursing staﬀ to accomplish. B. Goals that are set slightly higher than the patient can achieve C. Goal statements that are observable and measurable D. Goals that the patient should reach as a result of planned nursing interventions

Correct Answer is ["A"]

Explanation

Choice A reason: A desired patient outcome or expected outcome is a goal that the patient and his family ask the nursing staﬀ to accomplish. This ensures that the patient’s needs and preferences are respected and met.

Choice B reason: A desired patient outcome or expected outcome is not a goal that is set slightly higher than the patient can achieve. This would be unrealistic and demotivating for the patient.

Choice C reason: A desired patient outcome or expected outcome is not a goal statement that is observable and measurable. This is a characteristic of a well-writen goal statement, but not a definition of a desired patient outcome or expected outcome.

Choice D reason: A desired patient outcome or expected outcome is a goal that the patient should reach as a result of planned nursing interventions. This shows the link between the nursing process and the patient’s progress.

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A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

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Naxlex Comprehensive Predictor Exams

Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)

Correct Answer is ["B"]

Explanation

Which statements describe a desired patient outcome or expected outcome? (Select all that apply)

Correct Answer is ["A"]

Explanation

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