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 C
Explanation
Choice A reason: Drainage, odor, appearance, and size provide incomplete wound documentation, missing critical details like location and depth. Comprehensive wound assessment requires precise measurements and site identification to track healing, guide treatment, and prevent complications like infection, making this choice insufficient for clinical standards.
Choice B reason: Size, odor, location, and depth omit key descriptors like appearance and drainage, which indicate infection or healing status. Wound documentation must include all measurable aspects to ensure accurate monitoring and treatment planning, rendering this choice inadequate for thorough medical records.
Choice C reason: Location, length, width, depth, appearance, and drainage form a complete wound description, capturing site, dimensions, tissue characteristics, and exudate. This comprehensive approach supports accurate tracking of healing, infection risk, and treatment efficacy, aligning with clinical guidelines for wound care documentation and management.
Choice D reason: Color, location, appearance, and drainage lack measurements like length, width, and depth, essential for monitoring wound progression. Omitting these quantifiable metrics hinders accurate assessment of healing or deterioration, making this choice incomplete for standardized wound documentation in clinical practice.
Correct Answer is B
Explanation
Choice A reason: Assessing pupils tests cranial nerves II (optic) and III (oculomotor), evaluating visual acuity and pupillary response, not cranial nerve I (olfactory), which governs smell. Pupil assessment is irrelevant to olfactory function, making this choice incorrect for testing the sense of smell.
Choice B reason: Cranial nerve I, the olfactory nerve, is responsible for the sense of smell. Instructing the client to identify a scent, such as coffee or vanilla, directly tests this nerve’s function. This is a standard neurological assessment method to evaluate olfactory integrity, making it the correct choice.
Choice C reason: Performing facial expressions tests cranial nerve VII (facial), which controls facial muscle movement. This is unrelated to cranial nerve I, which solely mediates olfaction. Facial expression assessment cannot evaluate smell, rendering this choice inappropriate for the specified cranial nerve test.
Choice D reason: Reading the Snellen chart tests cranial nerve II (optic) for visual acuity, not cranial nerve I, which is dedicated to smell perception. Visual testing does not assess olfactory function, making this choice incorrect for evaluating the olfactory nerve’s sensory capabilities.
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