Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Ongoing assessment

Focused assessment

Emergency assessment

Comprehensive assessment

Answer and Explanation

The Correct Answer is A

A. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

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Correct Answer is ["A","C","E","F"]

Explanation

A. Increased subcutaneous fat: Middle adulthood often sees an increase in fat deposits, particularly around the abdomen, due to changes in metabolism and hormonal shifts.

B. Increased skin turgor and moisture: Incorrect. Aging typically leads to decreased skin turgor and moisture, causing the skin to become drier and less elastic.

C. Decreased bone density: Bone density generally decreases due to reduced bone remodeling, increasing the risk of fractures and osteoporosis.

D. The skin is more elastic: Incorrect. Skin elasticity usually decreases with age, resulting in wrinkles and sagging.

E. Muscle mass gradually decreases: Muscle mass tends to decline with age, a condition known as sarcopenia, leading to reduced strength and physical capability.

F. Decreased auditory acuity: Hearing loss, particularly high-frequency hearing loss, is common as people age due to changes in the inner ear and other auditory structures

A. The client will teach back information about safe crutch walking. B. The client will demonstrate safe crutch walking. C. The client will not lean on the crutches to support their body weight. D. The client will ambulate 5 feet in one day. E. The client will walk 10 feet by day 2. F. The client will walk 20 feet by day 3. G. The client will explain 4 principles of crutch safety. H. The client will explain how to keep crutches in safe condition.

Correct Answer is ["D","E","F"]

Explanation

A. The client will teach back information about safe crutch walking.This is an essential component of client education and ensures that the client understands how to use crutches safely. However, this statement does not include a specific time frame, making it not a timed SMART goal.

B. The client will demonstrate safe crutch walking.Demonstration of skills ensures the client can safely perform crutch walking techniques. However, without a specific deadline, it does not qualify as a timed component.

C. The client will not lean on the crutches to support their body weight.This statement reinforces proper crutch technique to prevent nerve damage (e.g., axillary nerve compression). However, it lacks a specific timeframe, so it is not a timed SMART goal.

D. The client will ambulate 5 feet in one day. This goal is specific, measurable, and time-bound as it defines both the distance (5 feet) and the timeframe (one day), making it a timed SMART goal.

E. The client will walk 10 feet by day 2. This goal provides clear progression, stating that the client should ambulate 10 feet within two days, making it specific, measurable, and time-limited.

F. The client will walk 20 feet by day 3. This builds on the previous goals, ensuring incremental progress in crutch walking and clear expectations within a set timeframe.

G. The client will explain 4 principles of crutch safety.This is a knowledge-based goal that ensures the client understands the fundamentals of crutch safety. However, no specific timeframe is provided, so it is not a timed component.

H. The client will explain how to keep crutches in safe condition.This supports long-term safety and maintenance of crutches but does not specify when the client should demonstrate this knowledge, making it not a timed SMART goal.

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Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are physical changes that occur in middle adulthood? Select all that apply.

Correct Answer is ["A","C","E","F"]

Explanation

Correct Answer is ["D","E","F"]

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

The adult child of an older adult calls the nurse practitioner to report that the parent is becoming very confused after dark. What is this type of confusion named?

When assessing the abdomen, which assessment technique is used last?

A nurse has accepted a position in a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (place them in the selected order of performance.)

To what is a person referring when during an interview the person says, "I am a member of the sandwich generation?