Which of these best describes the step of the nursing process of assessment?
Gather data from the client through interview, physical exam, and observation to make judgments.
Use problem-solving and decision-making skills to prioritize outcomes and goals, and develop interventions to meet those goals.
Assess the effectiveness and achievability of the goals and the need for the interventions to be adjusted.
Use clinical judgment to evaluate data collected to formulate the client’s problems, including actual and potential problems.
The correct answer is: a) Gather data from the client through interview, physical exam, and observation to make judgments.
The Correct Answer is A
Choice A reason: Assessment in the nursing process involves collecting subjective and objective data via interviews, physical exams, and observations to inform clinical judgments. This foundational step identifies patient needs, guiding subsequent planning. Accurate data collection ensures comprehensive care, preventing oversight of critical health issues and supporting effective diagnosis and intervention in clinical practice.
Choice B reason: Using problem-solving to prioritize outcomes and develop interventions describes the planning step, not assessment. Assessment focuses on data collection, not goal-setting. Assuming this misaligns with the nursing process, risking premature intervention without thorough data, which could lead to ineffective care plans or missed health issues in patient management.
Choice C reason: Assessing goal effectiveness and adjusting interventions pertains to the evaluation step, not assessment. Assessment gathers data to identify needs, not evaluate outcomes. Misidentifying this risks skipping data collection, leading to incomplete assessments and inappropriate interventions, compromising patient safety and care quality in the nursing process.
Choice D reason: Using clinical judgment to formulate problems is part of diagnosis, not assessment. Assessment collects raw data, while diagnosis analyzes it to identify issues. Assuming this conflates steps, risking incomplete data collection, which could result in inaccurate diagnoses and ineffective care plans, undermining the systematic approach of the nursing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Abdominal distention is an unexpected finding, potentially indicating serious issues like bowel obstruction, ascites, or organ enlargement, requiring urgent reporting. Unlike normal findings like symmetry, distention demands investigation. Prompt documentation ensures timely diagnosis and intervention, critical for preventing complications in patients with abdominal abnormalities.
Choice B reason: Silver striae are expected from skin stretching (e.g., pregnancy or weight gain), not typically concerning unless new or severe. Distention is more urgent. Assuming striae require reporting risks diverting focus from serious findings, potentially delaying evaluation of critical abdominal conditions needing immediate medical attention.
Choice C reason: Borborygmus (bowel sounds) is a normal finding, indicating active digestion, unless absent or hyperactive. Distention is abnormal and urgent. Assuming borborygmus requires reporting risks misprioritizing normal findings, neglecting serious issues like distention, critical for timely diagnosis and management of abdominal pathology.
Choice D reason: Abdominal symmetry is expected in healthy assessments, unlike distention, which signals pathology. Assuming symmetry is unexpected risks overlooking abnormal findings, diverting focus from urgent issues like obstruction or ascites. Reporting distention ensures prompt evaluation, critical for addressing underlying causes and preventing complications in patients.
Correct Answer is A
Explanation
Choice A reason: The gastrointestinal tract does not provide oxygen to organs; this is the respiratory and circulatory systems’ role, delivering oxygen via lungs and blood. The GI tract focuses on digestion, absorption, and waste elimination, making this function unrelated to its physiological responsibilities.
Choice B reason: Elimination of waste is a core gastrointestinal function, achieved through defecation. The large intestine compacts waste into feces, expelling it via the rectum, a critical process for removing indigestible material and toxins, making this a valid GI tract function.
Choice C reason: Digestion of food is a primary gastrointestinal function, involving mechanical and chemical breakdown in the stomach and small intestine. Enzymes and acids process nutrients for absorption, a fundamental GI role, making this choice a correct description of its physiological tasks.
Choice D reason: Removing water-soluble waste is a gastrointestinal function, as the colon reabsorbs water, concentrating waste for elimination. This process ensures efficient waste management, distinguishing it from renal functions, making this a valid role of the GI tract in waste handling.
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