Which entry made my nurse most accurately documents a client's mood?
The client has a pleasant affect
The client appears happy with an elevated mood
The client self-isolated today
The client rate their mood 4 out of 10
The Correct Answer is D
A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.
B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.
C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.
D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Assessment, diagnosis, intervention, evaluation, discharge, documentation. Discharge and documentation are important but are not part of the core nursing process.
B. Assessment, planning, intervention, evaluation, discharge, follow-up. Follow-up is not a standard step in the nursing process.
C. Assessment, diagnosis, planning, interventions, evaluation, education. Education is important but is not one of the six standard nursing process steps.
D. (Re)Assessment, diagnosis, outcomes, planning, implementation, evaluation. This accurately outlines the nursing process, which involves reassessing the patient, diagnosing, setting expected outcomes, planning care, implementing interventions, and evaluating effectiveness.
Correct Answer is C
Explanation
A. Administer oxygen at 2 L/min.: Oxygen is necessary, but raising the head of the bed first can improve oxygenation more effectively and quickly.
B. Encourage coughing and deep breathing.: While effective, this should be done after positioning the patient appropriately to optimize oxygenation.
C. Raise the head of the bed.: The priority intervention for low oxygen saturation is to improve ventilation and perfusion by raising the head of the bed. This enhances lung expansion, making it easier for the patient to breathe.
D. Administer prescribed analgesic medication.: Pain management is important, but it is not the priority when oxygen levels are dangerously low.
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