It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

the beginning of each shift.

admission to the unit.

discharge.

the patient's wakening in the morning.

Answer and Explanation

The Correct Answer is A

A.   Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B.   While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C.   At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D.   While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.

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Correct Answer is C

Explanation

A. While literacy is an important consideration, the focus should be on understanding the patient's cultural background to ensure appropriate care and address any specific needs related to their ethnicity and traditions.
B. A financial history may be relevant but does not directly relate to the patient's immediate care needs regarding abdominal pain.
C. Cultural assessment is essential to understand the patient's values, beliefs, and preferences in healthcare, particularly in a diverse population, to ensure culturally competent care.
D. Psychological history could be useful in some cases, but it is secondary to cultural considerations in a patient with abdominal pain.

A. "You stand 20 feet away from the chart while I test each of your eyes." B. The number beside the largest print read is your visual acuity score! C. "I will be testing your vision with your reading glasses on." D. "You stand 50 feet away from the chart while I test each of your eyes."

Correct Answer is A

Explanation

A. The patient should stand 20 feet away from the Snellen chart to accurately measure visual acuity, which is the standard procedure.

B. The number beside the largest print is not the correct visual acuity score; the patient must read progressively smaller lines.
C. Testing with reading glasses is appropriate only for patients who need them for close-up vision, but the Snellen test typically measures distance vision.
D. The distance should be 20 feet, not 50 feet, to ensure proper testing conditions.

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It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

Correct Answer is C

Explanation

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

Correct Answer is A

Explanation

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

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The normal pattern of breathing is described as

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

If dehydration occurs, the blood pressure will