Mr. Smart is an 80-year-old patient who goes to see his primary care physician for complaints of nocturia. What is the patient experiencing?

Choice A reason: Assessment in the nursing process involves collecting subjective and objective data via interviews, physical exams, and observations to inform clinical judgments. This foundational step identifies patient needs, guiding subsequent planning. Accurate data collection ensures comprehensive care, preventing oversight of critical health issues and supporting effective diagnosis and intervention in clinical practice.

Choice B reason: Using problem-solving to prioritize outcomes and develop interventions describes the planning step, not assessment. Assessment focuses on data collection, not goal-setting. Assuming this misaligns with the nursing process, risking premature intervention without thorough data, which could lead to ineffective care plans or missed health issues in patient management.

Choice C reason: Assessing goal effectiveness and adjusting interventions pertains to the evaluation step, not assessment. Assessment gathers data to identify needs, not evaluate outcomes. Misidentifying this risks skipping data collection, leading to incomplete assessments and inappropriate interventions, compromising patient safety and care quality in the nursing process.

Choice D reason: Using clinical judgment to formulate problems is part of diagnosis, not assessment. Assessment collects raw data, while diagnosis analyzes it to identify issues. Assuming this conflates steps, risking incomplete data collection, which could result in inaccurate diagnoses and ineffective care plans, undermining the systematic approach of the nursing process.

Choice A reason: Assessing pupils tests cranial nerves II (optic) and III (oculomotor), evaluating visual acuity and pupillary response, not cranial nerve I (olfactory), which governs smell. Pupil assessment is irrelevant to olfactory function, making this choice incorrect for testing the sense of smell.

Choice B reason: Cranial nerve I, the olfactory nerve, is responsible for the sense of smell. Instructing the client to identify a scent, such as coffee or vanilla, directly tests this nerve’s function. This is a standard neurological assessment method to evaluate olfactory integrity, making it the correct choice.

Choice C reason: Performing facial expressions tests cranial nerve VII (facial), which controls facial muscle movement. This is unrelated to cranial nerve I, which solely mediates olfaction. Facial expression assessment cannot evaluate smell, rendering this choice inappropriate for the specified cranial nerve test.

Choice D reason: Reading the Snellen chart tests cranial nerve II (optic) for visual acuity, not cranial nerve I, which is dedicated to smell perception. Visual testing does not assess olfactory function, making this choice incorrect for evaluating the olfactory nerve’s sensory capabilities.