Choice A :

Comparing the client's vital signs with the previous ones is not the first action the nurse should take during an initial assessment. This is a part of an ongoing or focused assessment that monitors the client's response to treatment and identifies any changes in their condition.

Choice B :

Asking the client about their medical history and current medications is the correct action the nurse should take during an initial assessment. This is a part of collecting subjective data from the client that can provide valuable information about their health status, risk factors, allergies, preferences, and needs. This can help the nurse to identify any potential problems or complications related to the client's pneumonia and plan appropriate interventions.

Choice C :

Performing a head-to-toe physical examination of the client is not the first action the nurse should take during an initial assessment. This is a part of collecting objective data from the client that involves inspecting, palpating, percussing, and auscultating various body systems. However, before performing a physical examination, the nurse should obtain consent from the client, explain the purpose and procedure, and ensure privacy and comfort.

Choice D:

Evaluating the effectiveness of the prescribed antibiotics is not the first action the nurse should take during an initial assessment. This is a part of the evaluation phase of the nursing process that involves comparing the client's outcomes with the expected outcomes and modifying the plan of care as needed. However, before evaluating the effectiveness of any intervention, the nurse should first assess the client's baseline data and implement the intervention according to the plan of care.

Choice A :

The size, depth, and color of the wound are important indicators of the stage and severity of the pressure ulcer. Measuring these parameters can help monitor the healing process and guide the appropriate treatment.

Choice B:

The presence of drainage, odor, or infection can signal complications or poor healing of the pressure ulcer. Drainage can indicate excessive moisture or exudate that can impair wound healing. Odor can suggest bacterial colonization or necrotic tissue. Infection can cause systemic symptoms such as fever, malaise, or leukocytosis.

Choice C:

The type and frequency of dressing changes are essential components of pressure ulcer management. Dressings should be chosen based on the characteristics of the wound, such as the amount of exudate, the presence of necrotic tissue, or the need for debridement. Dressings should be changed as often as necessary to maintain a moist but not wet environment for wound healing.

Choice D :

The client's pain level and preferred analgesics are important data to collect because pressure ulcers can cause significant discomfort and affect the quality of life of the client. Pain can also interfere with wound healing by increasing stress and inflammation. Analgesics should be prescribed according to the client's needs and preferences, taking into account the potential side effects and interactions.

Choice E :

The client's nutritional status and fluid intake are not part of a problem-focused assessment on a client who has a pressure ulcer on their sacrum. These data are relevant for a comprehensive assessment that includes all aspects of the client's health and well-being. However, a problem-focused assessment is more narrow and specific to the presenting problem or issue. Therefore, choice E is not correct.

Choice A :

To determine the severity and location of the pain. This is not the best answer because the nurse already knows that the client is experiencing chest pain and shortness of breath, which are signs of a possible cardiac problem. The nurse should also ask about the quality, radiation, and aggravating or relieving factors of the pain, not just the severity and location.

Choice B:

To establish a baseline for evaluating interventions. This is the best answer because the nurse needs to know how severe the pain is before administering any medication or treatment, and then reassess the pain after the intervention to see if it was effective. The pain scale is a useful tool to measure the intensity of pain and compare it over time.

Choice C:

To assess the client's coping skills and anxiety level. This is not the best answer because the nurse should focus on relieving the pain first, as it is an emergency situation. The nurse can assess the client's coping skills and anxiety level later, when the pain is under control.

Choice D:

To identify any factors that aggravate or relieve the pain. This is not the best answer because the nurse should ask this question along with other questions about the pain characteristics, not as a single question. The nurse should also prioritize relieving the pain rather than identifying factors that may or may not affect it.

Choice A reason:.

Objective data is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. For example, vital signs, physical examination findings, and laboratory results are objective data. The client's report of feeling thirsty and hungry is not something that the nurse can observe directly, so it is not objective data.

Choice B reason:.

Subjective data is information obtained from the patient and/or family members and offers important cues from their perspectives. For example, the patient's pain level, feelings, beliefs, and preferences are subjective data. The client's report of feeling thirsty and hungry is something that only the client can describe, so it is subjective data. This is the correct answer.

Choice C reason:.

Primary data is information provided directly by the patient. For example, the patient's history, symptoms, and concerns are primary data. The client's report of feeling thirsty and hungry is primary data, but this is not the best answer because it does not specify whether it is subjective or objective. Primary data can be either subjective or objective depending on the source.

Choice D reason:.

Secondary data is information collected from a family member, chart, or other sources. For example, the patient's previous records, family history, and test results are secondary data. The client's report of feeling thirsty and hungry is not secondary data because it comes from the client directly, not from another source.

Choice A reason:.

Gordon's functional health patterns is a framework that categorizes the data into functional health patterns, such as activity-exercise, nutrition-metabolism, and elimination. This framework was developed by Marjory Gordon in 1987 and is widely used by nurses to assess the health status of individuals, families, and communities.

Choice B reason:.

Maslow's hierarchy of needs is a motivational theory in psychology that proposes a five-tier model of human needs, often depicted as a pyramid. The needs are physiological, safety, love and belonging, esteem, and self-actualization. This theory is not a framework for organizing data collected from an assessment of a client.

Choice C reason:.

Orem's self-care deficit theory is a nursing theory that states that people have an innate ability to perform self-care activities that maintain their health and well-being. The theory consists of three related theories: the theory of self-care, the theory of self-care deficit, and the theory of nursing system. This theory is not a framework for organizing data collected from an assessment of a client.

Choice D reason:.

Roy's adaptation model is a nursing theory that views the person as a bio-psycho-social being who is constantly interacting with a changing environment. The theory focuses on how the person adapts to stimuli through four adaptive modes: physiological-physical, self-concept-group identity, role function, and interdependence. This theory is not a framework for organizing data collected from.