The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is C
Explanation
A. This is a dark vertical line that can appear on the abdomen during pregnancy, typically extending from the pubic area to the navel, which is not what is depicted in the image of a Mongolian Spot.
B. A chronic skin condition that results in red, itchy, scaly patches; this does not match the appearance of a Mongolian Spot.
C. This is the correct answer as it refers to a blue-gray pigmentation commonly found on the backs and buttocks of infants, particularly in individuals of Asian or African descent.
D. These are small, white cysts that can appear on the skin, typically on the face, and are not consistent with the description of a Mongolian Spot.
Correct Answer is D
Explanation
A. Providing a safe and comfortable environment and applying critical thinking involves both objective and subjective data collection, not just one type.
B. While family members can contribute to patient care, the professional responsibilities of providing a safe environment and critical thinking in assessments fall to trained healthcare providers.
C. This process encompasses both subjective and objective data, as critical thinking requires integrating multiple types of information.
D. The actions described are essential professional responsibilities of trained healthcare providers, who must ensure a safe environment, apply critical thinking, and identify patient cues effectively.