The nurse conducts a physical assessment. What action should the nurse take when documenting a client's physical assessment?

Document by adding the date and time to the end of every entry.

Document data in a subjective manner to ensure accuracy.

Document information the previous nurse provided during report.

Document assessment findings as client care is provided.

Answer and Explanation

The Correct Answer is D

A. Document by adding the date and time to the end of every entry: While dating and timing entries is required, it is only part of proper documentation practice. Accurate, timely recording of findings as they occur is more critical for safe care and communication.

B. Document data in a subjective manner to ensure accuracy: Subjective documentation captures the client’s reported experiences, but objective data from physical assessment should be recorded factually, without interpretation, to ensure accuracy and reliability.

C. Document information the previous nurse provided during report: Information from prior shifts is useful for continuity of care but should not replace the nurse’s own assessment. Documentation must reflect the current nurse’s direct findings and observations.

D. Document assessment findings as client care is provided: Recording findings in real-time ensures accuracy, timeliness, and completeness. It provides a reliable account of the client’s status, supports clinical decision-making, and facilitates safe, coordinated care.

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Correct Answer is A

Explanation

A. A client who is reporting a severe headache and new vision changes: Sudden severe headache with vision changes may indicate a potentially life-threatening condition such as a stroke, aneurysm, or increased intracranial pressure. This client requires an immediate emergency assessment to prevent serious complications.

B. A client who requires assistance when transferring to the exam table: Needing help with transfers is important for safety but does not indicate an urgent medical condition. This task can be addressed after more critical clients are assessed.

C. A client who requires a follow-up physical for their medication refill: Routine follow-up for prescription refills is non-urgent and can safely be scheduled after emergency or acute cases are addressed.

D. A client who is reporting minor swelling and pain in their left foot: Minor swelling and pain are usually non-life-threatening. While assessment is necessary, it does not require immediate emergency evaluation compared to acute neurological or vision changes.

A. Explain the parts of the assessment and ask permission to move forward B. Return at a later time to complete the physical assessment and interview C. Get a different nurse to complete the physical assessment and interview D. Continue with the physical assessment so the client can get treatment

Correct Answer is A

Explanation

A. Explain the parts of the assessment and ask permission to move forward: Providing a clear explanation of the assessment process and asking for consent demonstrates respect for the client’s cultural values and personal boundaries. This approach helps reduce anxiety, promotes trust, and ensures the client feels in control of their care.

B. Return at a later time to complete the physical assessment and interview: Delaying the assessment may not address the client’s immediate health needs and does not actively engage the client in reducing their apprehension. It may also prolong anxiety without providing reassurance.

C. Get a different nurse to complete the physical assessment and interview: While changing nurses might help in some cases, it does not directly address the client’s apprehension or foster communication and trust. The underlying need is for explanation and consent, not just a change in personnel.

D. Continue with the physical assessment so the client can get treatment: Proceeding without consent disregards the client’s autonomy and may increase anxiety or distrust. It could violate ethical principles and negatively impact the nurse–client relationship.

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The nurse conducts a physical assessment. What action should the nurse take when documenting a client's physical assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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