In what patient situations would a partial ongoing assessment be best performed?
On initial evaluation by the home health nurse.
Reassessing a client for pain after giving pain medication.
Checking skin assessment on a patient with a medical device in place.
Preparing the client for discharge.
The Correct Answer is B
Choice A rationale
On initial evaluation by the home health nurse, a comprehensive assessment is typically performed to gather baseline data. This initial assessment is thorough and includes a detailed history and physical examination to understand the patient’s overall health status. It is not a partial ongoing assessment, which is more focused and conducted after the initial comprehensive assessment to monitor specific issues or changes in the patient’s condition.
Choice B rationale
Reassessing a client for pain after giving pain medication is an example of a partial ongoing assessment. This type of assessment is focused on evaluating the effectiveness of an intervention, such as pain medication, and determining if further action is needed. It involves collecting specific data related to the patient’s pain levels and response to treatment, rather than a comprehensive evaluation of their overall health.
Choice C rationale
Checking skin assessment on a patient with a medical device in place is also an example of a partial ongoing assessment. This focused assessment is conducted to monitor the condition of the skin around the medical device, looking for signs of pressure ulcers, infection, or other complications. It is not a comprehensive assessment but rather a targeted evaluation of a specific area of concern.
Choice D rationale
Preparing the client for discharge involves a comprehensive assessment to ensure that the patient is ready to leave the healthcare facility and can manage their care at home. This assessment includes evaluating the patient’s physical, psychological, and social needs, as well as their ability to perform activities of daily living. It is not a partial ongoing assessment, which is more focused and conducted during the course of care to monitor specific issues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Documenting the application of the medication is important for maintaining accurate medical records, but it is not the priority action when a patient is receiving a new medication.
Choice B rationale
Informing the patient about potential side effects is the correct answer. This action ensures that the patient is aware of what to expect and can report any adverse reactions promptly, which is crucial for their safety.
Choice C rationale
Checking the patient’s vital signs frequently is important, but it is not the priority action when a patient is receiving a new medication. The priority is to inform the patient about potential side effects.
Choice D rationale
Leaving the patient alone to rest is not appropriate when a patient is receiving a new medication. The nurse should monitor the patient and inform them about potential side effects.
Correct Answer is A
Explanation
Choice A rationale
“I can see this is very difficult for you.”. This response is appropriate as it acknowledges the client’s emotions and provides validation. It demonstrates empathy and encourages the client to express their feelings, which is essential in therapeutic communication.
Choice B rationale
“Please don’t cry, it’s not good for you.”. This response is inappropriate as it dismisses the client’s emotions and may make them feel invalidated. Crying is a natural response to emotional distress, and the nurse should support the client in expressing their feelings.
Choice C rationale
“Why are you crying?” This response is also inappropriate as it may come across as judgmental or dismissive. It does not provide the support and empathy the client needs during a difficult moment.
Choice D rationale
“Let’s move on to a different topic to distract you.”. This response is not appropriate as it avoids addressing the client’s emotions and may make the client feel that their feelings are not important. The nurse should focus on supporting the client through their emotional experience.
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