The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?

Explain the parts of the assessment and ask permission to move forward

Return at a later time to complete the physical assessment and interview

Get a different nurse to complete the physical assessment and interview

Continue with the physical assessment so the client can get treatment

Answer and Explanation

The Correct Answer is A

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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Correct Answer is D

Explanation

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.

A. Discuss with the client their risk factors for developing CAD. B. Have the client start exercising for at least 30 minutes a day. C. Encourage the client to attend a support group for CAD. D. Instruct the client to begin following a heart-healthy diet.

Correct Answer is A

Explanation

A. Discuss with the client their risk factors for developing CAD: Family history is a significant non-modifiable risk factor for coronary artery disease. Educating the client about their personal risk helps raise awareness and supports prevention strategies tailored to their needs.

B. Have the client start exercising for at least 30 minutes a day: While exercise is important for cardiovascular health, recommending a specific regimen without first assessing the client’s overall health, readiness, and risk factors may be unsafe.

C. Encourage the client to attend a support group for CAD: Support groups can be beneficial for individuals already diagnosed with CAD, but the client in this scenario has a family history and may not need immediate support group involvement.

D. Instruct the client to begin following a heart-healthy diet: Diet modification is an effective preventive measure, but it should be introduced as part of a broader discussion on risk factors and individualized planning rather than as an immediate directive.

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The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse is assessing a client whose parent has coronary artery disease (CAD). What should the nurse plan to incorporate into the client's care plan?

Correct Answer is A

Explanation

A nurse is documenting findings following the examination of a client. Which should the nurse include as part of the general survey?

Which information obtained during a history and physical examination should the nurse document as subjective data?

Exhibits Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

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The nurse is planning a health promotion program for a group of clients. What action should the nurse plan to take first when implementing this health promotion plan?

A nurse is educating staff nurses about the goals of timely and accurate documentation of health assessments. Which statement by a staff nurse indicates additional education is needed?

What is the purpose of the general survey?

The nurse is caring for a group of clients. Which client should the nurse plan to complete an emergency assessment on?