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)

Maslow’s hierarchy of needs

A head-to-toe assessment

Subjective data collection

Review of systems

Answer and Explanation

Correct Answer : B

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.

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Correct Answer is B

Explanation

Choice A reason: "Alcoholism is a disease that aﬀects the whole family.” is not the best response to the client’s husband. This response shows generalization, which is a communication technique that involves using statements that apply to most people in similar situations. It also shows lecturing, which is a communication barrier that involves giving unsolicited advice or information to the other person. It may make the client’s husband feel stereotyped, judged, or patronized, and may discourage further communication. Therefore, this choice is incorrect.

Choice B reason: "You sound frustrated in dealing with your wife’s drinking problem.” is the best response to the client’s husband. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s husband’s emotions, and invites him to express his concerns or fears. Therefore, this choice is correct.

Choice C reason: "I think you are a good person to stay here with your wife.” is not the best response to the client’s husband. This response shows praise, which is a communication technique that involves giving positive feedback or recognition to the other person. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It may make the client’s husband feel uncomfortable, embarrassed, or pressured, and may not address his underlying feelings or needs. Therefore, this choice is incorrect.

Choice D reason: “Have you discussed this subject at the support group meetings?” is not the best response to the client’s husband. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows probing, which is a communication barrier that involves asking too many or inappropriate questions to the other person. It may make the client’s husband feel defensive, invaded, or resentful, and may violate his privacy or confidentiality. Therefore, this choice is incorrect.

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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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)

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Naxlex Comprehensive Predictor Exams

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

Correct Answer is B

Explanation

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

Correct Answer is ["A"]

Explanation

During the planning step of the nursing process, the nurse performs which activity? Select one answer

The nurse preceptor is instructing the new nurse on appropriate communication techniques. The new nurse indicates a need for further teaching on using assertive communication, if she does which of the following when communicating with patients? Select one answer

A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

The young client says, “I’m really stressed out about this pregnancy.” When the Practical Nurse (PN) responds, “What about this pregnancy worries you?”, he or she is using the technique of:

Which of the following are approved nursing diagnoses? (Select all that apply)

The basis for designing and selecting nursing interventions to meet client needs is the:

Which of the following types of posture is best for the nurse to use when communicating with the patient? (Select all that apply)