Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

a head-to-toe assessment

subjective data collection

objective data collection

Maslow's Hierarchy of Needs

Coughed up 5 mL yellow sputum

Answer and Explanation

The Correct Answer is A

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

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Correct Answer is C

Explanation

A. The patient is vulnerable to develop the problem: This describes a risk diagnosis, where the patient has the potential to develop a condition but does not currently have it.

B. There is no evidence of defining characteristics: An actual nursing diagnosis must have defining characteristics (symptoms/signs).

C. A condition is currently present: An actual nursing diagnosis means the condition is already present, with observable signs and symptoms.

D. It is written as a two-part statement: Actual nursing diagnoses use a three-part statement:

Problem (diagnosis)
Etiology (cause)
Signs and Symptoms (evidence)

A. focused B. body systems C. subjective D. complete

Correct Answer is A

Explanation

A. Focused: A focused assessment is ongoing and directed at specific problems based on the patient’s condition (e.g., assessing pain, circulation, or respiratory status frequently).

B. Body systems: Body systems assessments are structured assessments that evaluate a particular system (e.g., cardiovascular, respiratory) rather than continuous monitoring.

C. Subjective: Subjective assessment includes patient-reported symptoms but does not define the type of continuous assessment nurses perform.

D. Complete: A complete (or comprehensive) assessment is done at admission, not continuously.

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Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Correct Answer is C

Explanation

Select the type of assessment which is performed continuously throughout nurse-patient contact:

Correct Answer is A

Explanation

When documenting events in a patient's chart, the nurse should chart:

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

Identify the two primary methods used to collect data:

When using the SOAP method of charting, S stands for subjective data which means:

The primary source of assessment information is:

Which of the following statements is correct about abbreviations?

To what does objective data refer when assessing a patient?

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)