How would a nurse document the condition in which a client has a normal state of awareness?
"Easily distracted, alternates between drowsiness and excitability."
"Disoriented, restless, agitated, hallucinating."
"Can't be aroused and does not respond to stimuli."
"Aware of self and environment."
The Correct Answer is D
A normal state of awareness is characterized by being aware of oneself and one's surroundings. In this case, a nurse would document the client's condition as being "aware of self and environment" to indicate that the client has a normal state of awareness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
During a lung assessment on a client suspected of having pneumonia, the nurse should report asymmetrical chest expansion to the physician immediately. Asymmetrical chest expansion can be a sign of a serious lung condition such as pneumonia. The other options (Breath sounds equal bilaterally, Bilateral symmetric vocal fremitus, and Chest symmetrical) are normal findings and do not need to be reported immediately.
Correct Answer is A
Explanation
The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the effectiveness of care (evaluation).
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