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
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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Related Questions
Correct Answer is C
Explanation
A. Covert: Covert data refers to information that is hidden, subjective, or not immediately observable, such as symptoms reported by the client. Voided volume is measurable and observable, so it is not covert.
B. Subjective: Subjective data is information reported by the client, such as feelings, perceptions, or symptoms. Since the urine output is a measurable and observable fact, it is not subjective.
C. Objective: Objective data is factual, measurable, and observable. The voided volume of 475 ml is a precise, quantifiable measurement, making it objective data.
D. Symptomatic: Symptomatic data pertains to symptoms experienced by the client, which are typically subjective. The documented urine output is a specific, quantifiable measurement and not a symptom.
Correct Answer is B
Explanation
A. "Do you smoke?" This is a closed-ended question that can be answered with a simple "yes" or "no." It doesn't encourage elaboration or detailed responses.
B. "How are you feeling?" This is an open-ended question that encourages the client to provide more detailed and descriptive responses about their current state or feelings. It allows the client to share more information and gives the nurse a better understanding of their condition.
C. "Are you feeling well?" Similar to option A, this is a closed-ended question. It prompts a "yes" or "no" answer without inviting further discussion or detailed explanation.
D. "Do you use any illicit drugs?" This is another closed-ended question that requires a "yes" or "no" answer. It does not provide the opportunity for the client to discuss their drug use in detail.
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