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 C

Explanation

A. "You are probably sad about that" assumes the client’s emotions rather than allowing them to express their own feelings.
B. "Are you feeling sad, depressed, angry, or upset?" is a closed-ended question that may limit the client’s ability to fully express emotions.
C. "How does that make you feel right now?" is correct because it is an open-ended question that encourages the client to explore and express their emotions in their own words.
D. "What was the cause of your wife's death?" shifts the focus away from the client’s emotions and may come across as insensitive.

A. Client is experiencing a fluid deficit. B. Adventitious sounds are present. C. Hyperinflation of the lungs. D. Client has a pectus carinatum.

Correct Answer is C

Explanation

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

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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

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A nursing student correctly describes a risk diagnosis by which of the following statements?

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?

The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

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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?

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?