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 B
Explanation
Choice A reason: Inspection, palpation, and auscultation is incorrect, as palpation before auscultation can alter bowel sounds by stimulating peristalsis. Abdominal assessment requires auscultation first to capture natural bowel activity, followed by palpation to avoid disrupting the acoustic findings critical for diagnosing conditions like obstruction.
Choice B reason: Inspection, auscultation, and palpation is the correct sequence for abdominal assessment. Inspection identifies visible abnormalities, auscultation captures unaltered bowel sounds, and palpation assesses tenderness or masses. This order prevents palpation from affecting auscultatory findings, ensuring accurate evaluation of gastrointestinal function and potential pathologies.
Choice C reason: Auscultation, inspection, and palpation disrupts the logical flow of abdominal assessment. Inspection should precede auscultation to note visible abnormalities that may guide listening. Starting with auscultation risks missing contextual visual cues, reducing the effectiveness of the assessment and potentially overlooking critical signs.
Choice D reason: Palpation, auscultation, and inspection is incorrect, as palpation first can stimulate or suppress bowel sounds, skewing auscultation results. Inspection must initiate the process to identify visible issues, followed by auscultation and palpation, to maintain accuracy in assessing abdominal conditions like peritonitis or organ enlargement.
Correct Answer is C
Explanation
Choice A reason: Warm, dry skin is a normal finding, reflecting adequate circulation and hydration, expected in healthy integumentary assessments. It’s not concerning unless accompanied by fever or dehydration. Assuming this is unexpected risks overcomplicating care, diverting focus from actual abnormalities like pressure injuries requiring intervention in skin assessments.
Choice B reason: A clear IV site without drainage is expected, indicating no infection or infiltration. Unexpected findings involve redness or leakage. Assuming this is abnormal risks unnecessary interventions, diverting attention from true integumentary issues like pressure injuries, critical for preventing complications in patients with prolonged IV therapy.
Choice C reason: A stage 1 pressure injury, with non-blanchable erythema, is an unexpected and concerning finding, indicating early tissue damage requiring intervention like repositioning or pressure relief. Unlike normal skin findings, this signals risk of progression, necessitating prompt documentation and care to prevent worsening ulcers in vulnerable patients.
Choice D reason: Skin color consistent with racial heritage is expected and normal, reflecting genetic pigmentation. Unexpected findings involve changes like pallor or cyanosis. Assuming this is abnormal risks misinterpretation, neglecting actual integumentary issues like pressure injuries, critical for accurate assessment and timely intervention in skin health.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.