The nurse is preparing to conduct a physical assessment on a client who appears uncomfortable and slightly anxious. Which action is the most appropriate for the nurse to take?

Recommend a psychiatric consult

Proceed with the exam by completing invasive aspects first.

Stay with the client at all times to provide assistance.

Use a relaxed manner and reassure the client as necessary.

Answer and Explanation

The Correct Answer is D

A. Recommending a psychiatric consult is premature and not appropriate for routine anxiety during an assessment.

B. Starting with invasive aspects may increase the client's anxiety. Instead, the nurse should ease the client into the exam.

C. Staying with the client at all times may not be necessary and could make the client feel more uncomfortable.

D. Using a relaxed manner and reassuring the client can help reduce anxiety and make the physical assessment more comfortable.

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Correct Answer is A

Explanation

A. The patient is the primary source of information regarding their pain tolerance, as pain is subjective and only the patient can accurately describe their experience.

B. A patient's roommate cannot reliably report on the patient's pain experience.

C. The CNA may observe signs of pain but cannot determine the patient's subjective pain tolerance.

D. The nurse can assess the patient's pain based on behaviors and reports but relies on the patient for direct information.

A. Wash hands prior to examination in the examination room. B. Approach the client from the left side of the examination table. C. Recap used needles and place them in the sharps container. D. Remove gloves only after the examination is over.

Correct Answer is A

Explanation

A. Hand hygiene is the most important action to prevent the spread of infection before any physical examination.

B. Approaching from the left side is unnecessary unless required by specific patient needs.

C. Needles should never be recapped as this increases the risk of needlestick injuries.

D. Gloves should be worn when appropriate but should not be the first action before an examination. Hand hygiene is essential before touching the client or any instruments.

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The nurse is preparing to conduct a physical assessment on a client who appears uncomfortable and slightly anxious. Which action is the most appropriate for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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