Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

"The documentation satisfies legal standards established by health care organizations and institutions."

"Documentation of the initial assessment becomes the foundation for the entire nursing process."

"Incorrect conclusions may be made without the documentation of the nurse's opinions."

"Health care institutions have established policies regarding documentation of initial assessments."

Answer and Explanation

The Correct Answer is B

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

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Correct Answer is B

Explanation

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

A. Groin B. Heels C. Elbows D. Toes

Correct Answer is A

Explanation

A. The groin is correct because skin folds in obese clients are prone to excessive moisture, which increases the risk of fungal or bacterial infections such as intertrigo. The nurse should inspect these areas for redness, irritation, or signs of infection.
B. The heels are at risk for pressure injuries but are not typically associated with excessive moisture or diaphoresis.
C. The elbows are not a common site for moisture retention and are not a priority for inspection in this case.
D. The toes can be prone to fungal infections (e.g., athlete’s foot), but the primary concern in an obese client with diaphoresis is the skin folds, particularly in the groin and under the breasts.

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Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Correct Answer is B

Explanation

The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

Correct Answer is A

Explanation

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?