NCLEX- RN PassPoint Practice exam results

A young female client is receiving chemotherapy and mentions to the nurse that they and their spouse are using a diaphragm for birth control. Which information is most important for the nurse to discuss?

infection control Explanation: The risk for becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes.

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by

turning the client's head suddenly while holding the eyelids open. Explanation: To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting.

During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, "I do not want you to contact my family. I don't even have to talk to you." Which statement is the most appropriate nursing response?

"Anything you say about your feelings is confidential but your care involves the whole team so we can all work together." Explanation: Being truthful with the client and reinforcing the need for prevention of harm to self or others clarifies what the client can expect from the team. Challenging the client will contribute to a sense of low self-worth. "It sounds like you are not concerned about your problems and why you are in the hospital" is nontherapeutic and devalues the client's self-perception. Negotiating a special agreement or luring the client into the interview will not be therapeutic. "I need you to trust me and the staff members in the facility" does not offer a therapeutic way to establish trust.

A client is admitted to the psychiatric unit with delusional thinking. The client, who is overweight and has a history of eating when stressed, now shows a lack of interest in eating at meal times. The client states, "I am unworthy of eating. My children will die if I eat." Which response by the nurse is most appropriate?

"That sounds scary. Tell me more about how you are feeling." Explanation: The most therapeutic response addresses the client's concern and acknowledges the client's fear. By asking an open-ended question the nurse will prompt more information from the client. The nurse should not discuss the content of the delusion with the client. Additionally, the nurse cannot guarantee the children's safety (false reassurance). Stating the client is here because he or she believes things that are untrue may be correct, but it is argumentative and a nontherapeutic statement.

Discharge planning is being finalized for a neonate who was born at 32 weeks' gestation and was diagnosed with retinopathy of prematurity. What should the nurse tell the parents?

"An ophthalmologist will examine the baby before discharge." Explanation: An ophthalmologist commonly examines neonates with retinopathy of prematurity before discharge. Serial eye examinations are then necessary to determine the extent of damage. An optometrist can't provide follow-up treatment for the neonate with retinopathy of prematurity because some neonates require cryotherapy and laser photocoagulation therapy, both of which must be performed by an ophthalmologist. The parents should contact the early intervention program to set up an individualized educational plan for their child before he reaches school age. Because the neonate may have permanent vision loss, intervention before school age is important to the child's growth and development. The school nurse is only involved with individualized educational plans for children of school age. The neonate may not be blind, so suggesting a support group for the blind is inappropriate.

The nurse is teaching an older adult how to prevent falls. What should the nurse tell the client?

Instruct the client to rise slowly from a supine position. Explanation: Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurologic changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light that can cause a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurologic changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. Assistive devices (hand rails, cane, walkers) help reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain before surgery?

Place the client in semi-Fowler position with the knee gatch raised. Explanation: Appendicitis typically begins with periumbilical pain, followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney's point (located halfway between the umbilicus and the right iliac crest). To relieve pain before surgery, the nurse assists the client into a comfortable position with the knees drawn to the chest and the head of the bed slightly elevated. The nurse may also administer analgesics and ice packs if prescribed; heat is avoided as heat may precipitate rupture of the appendix. The abdomen is not palpated or massaged more than necessary to avoid increasing the pain. Distraction with music may be helpful, but positioning, using ice packs, and analgesics are most effective.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?

The client is able to refuse medications. Explanation: Competent clients have the right to refuse medications. A client is considered competent unless the court has declared that the client is incompetent. Even though the client is an involuntary admission, nothing in the scenario indicates the client is not competent and thus able to be involved in treatment planning. Because the client was admitted involuntarily, the client is not able to obtain release. A guardian or representative who is responsible for giving consent is appointed by the court for a client who has been determined to be incompetent.

An adolescent tells the nurse that they would like to use tampons during their period. What should the nurse do first?

Provide information about preventing toxic shock syndrome. Explanation: The nurse should provide the adolescent with information about toxic shock syndrome because of the identified relationship between tampon use and the syndrome's development. Additionally, about 95% of cases of toxic shock syndrome occur during menses. Most adolescent females can use tampons safely if they change them frequently. Using tampons is not related to menstrual flow or sexual activity. There is no need to refer the girl to a gynecologist; a nurse can provide health teaching about tampon use.

A client is taking 50 mg of lamotrigine daily for bipolar disorder. The client shows the nurse a rash on their arm. What should the nurse do?

Report the rash to the health care provider (HCP). Explanation: The nurse should immediately report the rash to the HCP because lamotrigine can cause Stevens-Johnson syndrome, a toxic epidermal necrolysis. The rash is not a temporary adverse effect. Giving the client an ice pack and questioning the client about recent sun exposure are irresponsible nursing actions because of the possible seriousness of the rash.

The nurse is discharging a newborn with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement?

"I should use a pillow to elevate my child's foot as they sleep." Explanation: Elevating the extremity at different points during the day is helpful to prevent edema, but pillows should not be used in the crib because they increase the risk for sudden unexplained infant death syndrome (SUIDS). A change in the color of the toes is a sign of impaired circulation and requires medical evaluation. Children typically need a series of 5 to 10 casts to correct the deformity. Infants with clubfeet still need frequent holding like any other newborn.

The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of what? Select all that apply. discussion of pertinent information the client's agreement to the plan of care freedom from coercion caregiver preference and opinion verification from next of kin

-discussion of pertinent information -the client's agreement to the plan of care -freedom from coercion Explanation: Discussion of pertinent information, the client's agreement to the plan of care, and freedom from coercion are important factors in informed consent. Caregiver preference and opinion could be perceived as coercion. Informed consent does not require verification from next of kin.

A nurse at a healthcare facility has just reported for duty. What should the nurse do to ensure maximum efficiency of change-of-shift reports?

Come prepared with the material required to take notes. Explanation: The nurse should come prepared with material required to take notes during the change-of-shift report. The nurse should not delay the meeting for change-of-shift report by speaking to each staff member individually. Change-of-shift reports are not normally conducted in the presence of physicians; hence, the nurse need not wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?

Inform the physician immediately. Explanation: The client should notify the physician immediately because a breast lump may be a sign of breast cancer. The client shouldn't squeeze the nipple to check for drainage until the physician examines the area. The client shouldn't wait until after the next menstrual period to inform the physician of the breast lump because prompt treatment may be necessary. Placing a heating pad on the area would have no effect on a breast lump.

When preparing to draw up 8 units of a short-acting insulin and 20 units of a long-acting insulin in the same syringe, the nurse should use which technique?

Inject air in the vial with the long-acting insulin first. Explanation: The air is injected into the long-acting insulin first. Air is then injected into the short-acting insulin, and the short-acting insulin is withdrawn. Then the long-acting insulin is withdrawn. It does matter which insulin is drawn up first because the nurse does not want to contaminate the short-acting insulin with the long-acting insulin. It is not necessary to use a high-dose insulin syringe to prepare 28 units of insulin.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next?

Proceed to suction the client's tracheostomy. Explanation: The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection. The nurse must wear protective personnel equipment when caring for a client with a MRSA infection.

A nurse overhears a fellow staff member talking about the parent of a child for whom the staff nurse is caring. The nurse is telling others private information that the parent had shared. What is the best response by the nurse overhearing the conversation?

Talk to the staff member privately about this. Explanation: The best approach is to talk to the staff member privately about the information that the parent shared. This information is confidential and should not be disclosed. Reporting the incident to the nurse-manager is appropriate once the nurse has spoken to the staff member privately. The decision to contact a privacy officer is dependent on the seriousness of the breech and should be determined after discussion with the nurse manager. Talking to the staff in general about confidentiality may be beneficial. However, the nurse needs to speak with the staff member in private first.

A 7-year-old child has taken a game from the hospital playroom that was supposed to remain in that area. The nurse should discuss the problem with the mother and make which recommendation?

The child needs to apologize and return the game to the playroom. Explanation: In most situations, children ages 5 to 8 have not yet developed respect for others' property. They may take something, such as money or a game, because they are attracted to it. Serious punishment is inappropriate.A long talk is not warranted in this situation because the child is unable to maintain attention for a long period.This behavior usually is not an indication of a serious problem in the child.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education?

The nurse dries from forearms up toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's

adverse effects. Explanation: When developing a drug therapy regimen that won't interfere with a client's lifestyle, the nurse must consider the drug's adverse effects because these may result in noncompliance. A drug's excretion route, peak concentration time, and steady-state duration of action are important considerations when developing a drug therapy regimen; however, they're related to the drug's physiologic effects and don't affect the client's lifestyle.

After teaching the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching?

application of powder to the skin under the cast Explanation: Powder should not be applied to the skin beneath the cast because powder can cause irritation and skin breakdown. The parent would need further teaching about avoiding this measure. Checking the smoothness of the cast edges, covering the cast around the perineum, and inspecting inside the cast are all appropriate actions for the child with a spica cast to help prevent skin breakdown.

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating ordered antibiotic therapy, the nurse should prepare the client for:

delivery. Explanation: After rupture of the membranes in a client who has a fever or other signs or symptoms of infection, the fetus must be delivered promptly. Data obtained by amniocentesis or sonography wouldn't change the decision to deliver the fetus. Tocolytic drugs are used to arrest preterm labor.

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when the nurse reflects on the decision-making process and the role it will play in making future decisions?

evaluating Explanation: Evaluating an ethical decision involves reflecting on the process and considering those elements that will be helpful in the future. The nurse may also question how this experience can improve reasoning and decision making in the future. Diagnosing the ethical problem involves stating the problem clearly. Planning includes identifying the options and exploring the probable short-term and long-term consequences. Implementing includes the implementation of the decision and comparing the outcomes of the action with what was considered and hoped for in advance.

During the initial assessment of a laboring client, the nurse notes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints?

headache, blurred vision, and facial and extremity swelling Explanation: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most clients with preeclampsia have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia.

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention?

removing the initial dressing for incision inspection Explanation: Nursing care should never include removing the initial dressing put on in the operating room. Therefore, if a nurse performs this action, intervention is needed. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate and therefore incorrect answers to this question.

A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should:

increase the client's fluid intake to 3,000 mL/day. Explanation: The most appropriate nursing action is to first increase the client's fluid intake to 3,000 mL/day to soften stool.A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool.Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement.While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement.

The client states they wash their feet endlessly because they "are so dirty that I can't put on my socks and shoes." The nurse recognizes the client is using ritualistic behavior primarily to relieve discomfort associated with which feeling?

intolerable anxiety Explanation: The client with an obsessive-compulsive disorder has an uncontrollable and persistent need to perform a behavior that helps relieve intolerable anxiety.In depression, the client feels extreme sadness. Depression is not alleviated by performing obsessive-compulsive actions.Ambivalence refers to two simultaneous opposing feelings.An irrational fear is called a phobia. Phobic behavior is associated with extreme avoidance behavior when confronted with the feared object, not with ritualistic behaviors.

A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells?

liver Explanation: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

A client with acute diarrhea is requesting an as-needed medication for loose, watery stools. After reviewing the physician's orders, which medication should the nurse administer?

paregoric 5 ml P.O. Explanation: Paregoric helps decrease peristalsis and diarrhea caused by muscle spasms of the GI tract. Morphine sulfate, chlorpheniramine polistirex and hydrocodone polistirex, and alprazolam aren't indicated for diarrhea.

A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question?

rectal temperatures every 4 hours Explanation: The platelet count indicated that the client is a risk for bleeding. The low RBC can cause fatigue, so the activity order is appropriate. The hematocrit is reflective of the low RBC count. The white blood cell count is normal, so a semiprivate room or regular diet is acceptable.

The nurse is assessing a client whose blood pressure is dropping and heart rate and respiratory rate are increasing. Which finding indicates the client is at risk for hypovolemic shock?

severe hemorrhage Explanation: Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.

A client reports having a dry, hacking cough that disturbs sleep at night. Which antitussive agent and intervention are most appropriate for this client?

using a cooling mist humidifier and administering dextromethorphan Explanation: Dextromethorphan is the most widely used antitussive in Canada because it produces few adverse reactions while effectively suppressing a cough. A cool mist humidifier will help open nasal passages. Benzonatate is used for cough associated with respiratory conditions and chronic pulmonary diseases. Opioid antitussives, such as codeine and hydrocodone, are reserved for treating unruly coughs usually associated with lung cancer.

Which instructions should the nurse include in the teaching plan about skin care for the parent of a child with atopic dermatitis?

Use a mild soap followed by patting the skin to dry it. Explanation: Care of the skin is basic to the treatment of atopic dermatitis. Treatment includes use of a mild soap, not allowing the child to soak in the tub, which dries the skin, and patting the skin with a towel after the bath to help keep moisture in the skin. Soaking in the tub would prolong the child's exposure to water, which has a drying effect on the skin. The goal of care is to keep the skin moist. Antibacterial soap is harsh and drying to the skin, possibly exacerbating the condition. Using a strong detergent for washing the child's clothes is inappropriate because soap left in the clothing may be harsh and irritating to the infant's skin.

A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat intertrochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?

client anxious and confused Explanation: The client is anxious and confused is the appropriate answer. Postoperative complications of hip fractures include hemorrhage, pulmonary emboli, and fat emboli. Anxiety and confusion may be indicative of hypoxia as a result of any of these complications and needs further investigation. Capillary refill of 2-3 seconds is an expected finding. Edema is present from both the injury and the surgical intervention. 100 milliliters of bright red drainage 6 hours after surgery should be watched, but is not of immediate concern.

The nurse plans care for a child with sickle cell disease in vasoocclusive crisis. What rationale does the nurse use for increasing the child's fluid intake?

Decreased blood viscosity prevents the sickling process. Explanation: Treatment of a child in vasoocclusive crisis from sickle cell disease includes measures to prevent further sickling. Sickling occurs in the presence of decreased oxygen tension and alterations in pH. The hard sickle-shaped cells catch on each other and can eventually occlude vessels; this occlusion decreases oxygenation of the area and increases the sickling process. Increasing fluids will increase hemodilution and prevent the clumps of sickle cells from occluding vessels. Children in sickle cell crisis do not lose more water than normal through diaphoresis. The life span of a normal red blood cell is 120 days; there is no way to increase this life span. Hemolysis refers to the breakdown of red blood cells, something to be avoided in a child with sickle cell disease.

A multigravida prenatal client with a history of postpartum depression tells the nurse that they are taking measures to make sure that they don't suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?

current medications Explanation: St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, they can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.

A healthcare provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement?

time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR) Explanation: Direct fetal scalp electrode placement is the most accurate way to assess FHR. Documentation should include the time the electrode was placed, the name of the HCP or nurse practitioner who performed the procedure, and the FHR. Direct fetal scalp electrodes don't monitor maternal uterine contractions. A Doppler transducer (an external, not internal device) is applied to the mother's abdomen to measure FHR, using high-frequency ultrasound. Unlike the fetal scalp electrode, it doesn't directly measure FHR. The fetal scalp electrode doesn't measure maternal or fetal movements.

The nurse is teaching a client about insulin administration. Which statement if made by a client would indicate to the nurse the client understands insulin administration teaching?

"I will use my abdominal injection site if I want to jog." Explanation: If the client engages in an activity or exercise that focuses on one area of the body, that area may cause inconsistent absorption of insulin. A good regimen for a jogger is to inject into the abdomen. A jogger may have inconsistent absorption in the legs or arms with strenuous running. The higher the gauge the smaller the needle, and the more comfortable the injection. The gauges for insulin syringes range from 28 to 31. Sites should be rotated on one anatomical site for at least one week before changing to another body site. Insulin should not be exposed to extreme temperatures and direct sunlight. Insulin can be kept at room temperature for up to four weeks.

Ask to speak to the client directly on the phone. Explanation: The first thing that the nurse should do is to speak with the client on the phone and question them about perceptions or reasons that are interfering with them going to the sheltered workshop. This conveys that the nurse is interested and willing to help the client. The nurse should call the director of the work center for information only if the nurse receives the client's permission. Making preparations for the client's admission is inappropriate and would not be done until the client's needs have been assessed and it is determined that the client requires hospitalization. Making an appointment with the HCP is inappropriate until the nurse has assessed the client's needs.

A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the parent of a client who lives at home. The parent reports that the client has not been taking their medication and now is refusing to go to the work center where she they have worked for the past year. What action should the nurse take first?

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch up the child's vaccinations?

Review nationally published immunization guidelines. Explanation: National advisory committees on immunization practices review vaccination evidence and update recommendations yearly. Current vaccination catch-up schedules are readily available on their websites. The lack of vaccinations is a strong indicator that the child probably does not have an HCP. Even if the client had a provider, however, that person might be difficult to reach on a weekend during the time frame of a vaccination clinic. If consulted, the pharmacist would most likely have to review the latest guidelines that are equally available to the nurse. Reading each of the manufacturer's inserts for multiple vaccines would be time consuming, and synthesis of the information could possibly lead to errors.

Sodium polystyrene sulfonate is prescribed for a client following a crush injury. Which finding indicates the drug has been effective?

The serum potassium is 4.0 mEq/L (4.0 mmol/L). Explanation: Following a crush injury, serum potassium rises to high levels. Sodium polystyrene sulfonate is a potassium-binding resin. The resin combines with potassium in the colon and is then eliminated, and serum potassium levels should come back to normal. Normal serum potassium is 3.5 to 5.3, so a level in this range indicates that the medication has been effective. A weak, irregular pulse and tall peaked T waves on ECG are signs of hyperkalemia, and muscle weakness is a sign of hypokalemia.

During a mental health assessment interview, a client does not make eye contact with the nurse. The nurse suspects this behavior is culturally based. What should the nurse do first in relation to this assumption?

Observe how the client and the client's family interact with each other and with other staff members Explanation: Assessing a client's interactions with others is a helpful way to determine the client's usual behavior patterns. This may also help a nurse determine what a behavior means to a client. Reading and consulting others about a cultural behavior pattern is useful only in assisting an understanding of an individual client after a nurse has had an opportunity to assess and observe the client directly. The nurse has to be able to assess and care for the client as an individual as well as a member of a cultural community.