The nurse recognizes the importance of an accurate, thorough ...

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The nurse recognizes the importance of an accurate, thorough physical assessment and health history. Which of the following facets of care are directly dependent on the database of infor-mation collected? (Select all that apply.)
 
  1. Identification of client likes and dislikes
  2. Support of the nurse-client relationship
  3. Selection of client-centered interventions
  4. Revision of client care plan as appropriate
  5. Evaluation of nursing and client outcomes
  6. Identification of appropriate nursing diagnosis

Question 2

Which of the following nursing actions best shows an understanding of the guiding principles regarding the inspection method of physical assessment? (Select all that apply.)
 
  1. Positioning the client so as to expose body parts adequately but with attention to modesty
  2. Providing a general survey of the client's body, area by area and extremity by ex-tremity
  3. Comparing each area inspected with the same area on the opposite side of the client's body
  4. Evaluating each body area for size, shape, color, symmetry, position, and abnor-malities
  5. Providing sufficient lighting to ensure adequate visualization of the client's body during the assessment
  6. Conducting the assessment in a time conscious manner to minimize the client's physical and emotional discomfort

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Answer to Question 1

ANS: 3, 4, 5, 6
The accuracy of the database allows for the development of an individualized nursing diagnosis. Physical assessment findings determine the etiology of the diagnosis so that the selection of in-terventions is appropriate for the care plan. Physical assessment is ongoing, and thus the care plan changes with the client's condition. Monitor the client's progress and responses to therapies to review existing diagnoses and identify new problems.

Answer to Question 2

ANS: 1, 3, 4, 5
The inspection portion of the assessment is detail-oriented and must be done thoroughly, which may be time-consuming.

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Thank you!

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