A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. Which type of assessment would the nurse perform?

Focused Assessment

Emergency assessment

Initial assessment

Time-lapsed assessment

Answer and Explanation

The Correct Answer is A

Nursing assessments are categorized based on timing, purpose, and patient condition. A focused assessment is performed when a patient presents with a specific complaint or when a known problem requires reassessment. It targets a particular body system or symptom rather than conducting a full head-to-toe evaluation. This type of assessment is commonly used in outpatient and follow-up settings where the patient has an existing or recurring health issue.

Rationale:
A. Focused assessment is appropriate because the client is presenting with a specific complaint of abdominal pain that has been previously evaluated. The nurse concentrates on the gastrointestinal system and related symptoms to assess changes in condition. This targeted approach allows efficient evaluation of the current problem without repeating a full system assessment.

B. Emergency assessment is used in life-threatening situations where immediate intervention is required, such as airway compromise, severe trauma, or cardiac arrest. Although abdominal pain can sometimes indicate a serious condition, the scenario does not suggest an immediate life-threatening emergency. Therefore, this type of assessment is not indicated.

C. Initial assessment is a comprehensive head-to-toe evaluation performed when a patient first enters care or is admitted to a facility. It establishes a baseline health status and identifies all existing problems. Since the client has already been seen for this issue before, an initial assessment is not appropriate.

D. Time-lapsed assessment is conducted after a significant period of time has passed since the last assessment to evaluate changes in a patient’s overall condition. It is often used in long-term care or chronic disease monitoring. This is a return visit for a specific complaint rather than a long-term reassessment, so this does not apply.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Vitamin C (ascorbic acid) is a water-soluble vitamin essential for collagen synthesis, wound healing, and maintenance of capillary integrity. Deficiency leads to impaired connective tissue strength and increased fragility of blood vessels. This results in characteristic clinical manifestations affecting the skin, gums, and mucous membranes. Severe deficiency can lead to scurvy, a condition marked by widespread bleeding and poor wound healing.

Rationale:
A. Swollen tongue (glossitis) is more commonly associated with deficiencies of B-complex vitamins, particularly vitamin B12 and folic acid. While nutritional deficiencies can affect oral tissues, glossitis is not a hallmark feature of vitamin C deficiency. Therefore, this finding is not expected.

B. Impaired vision is typically associated with vitamin A deficiency, which affects retinal function and leads to night blindness and visual disturbances. Vitamin C deficiency does not directly impair visual pathways or retinal function.

C. Diarrhea is not a characteristic manifestation of vitamin C deficiency. While excessive intake of vitamin C may cause gastrointestinal upset and loose stools, deficiency is more associated with bleeding and connective tissue weakness rather than increased bowel motility.

D. Bleeding gums are a classic sign of vitamin C deficiency due to impaired collagen synthesis and weakened capillary walls. This leads to fragile blood vessels that rupture easily, especially in the gingival tissues. Patients may also present with gum swelling, loosening of teeth, and spontaneous bleeding, all of which are hallmark features of scurvy.

A. Don sterile gloves before inserting the indwelling urinary catheter. B. Test the balloon on the indwelling urinary catheter before insertion. C. Apply an oil-based lubricant to the indwelling urinary catheter. D. Use one cotton swab to clean the client's urinary meatus.

Correct Answer is A

Explanation

Insertion of an indwelling urinary catheter requires strict aseptic technique to prevent introduction of microorganisms into the urinary tract. The urinary system is normally sterile, and catheterization increases the risk of catheter-associated urinary tract infections if sterile technique is not maintained. Proper preparation, including sterile field setup and use of sterile equipment, is essential to reduce infection risk. Each step of the procedure is guided by infection control principles.

Rationale:
A. Donning sterile gloves before inserting the indwelling urinary catheter is a critical step in maintaining aseptic technique. The catheter is considered a sterile device that directly enters a sterile body system, so any contamination can lead to urinary tract infection. Sterile gloves help prevent transfer of microorganisms from the nurse’s hands to the catheter or urinary meatus during insertion.

B. Testing the balloon on the indwelling urinary catheter before insertion is a recommended step to ensure the balloon is intact and functioning properly. However, it does not replace the need for sterile technique during insertion. While important for equipment safety, it is not the most critical action related to infection prevention in this question.

C. Applying an oil-based lubricant to the indwelling urinary catheter is incorrect because oil-based products can damage latex catheters and increase the risk of irritation or infection. A sterile water-soluble lubricant should be used instead to reduce friction during insertion and maintain catheter integrity.

D. Using one cotton swab to clean the client’s urinary meatus is incorrect because proper sterile technique requires multiple swabs, typically using a separate sterile swab for each stroke of cleansing. This helps prevent recontamination of the area and ensures adequate removal of microorganisms before catheter insertion.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. Which type of assessment would the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assessing a client who has vitamin C deficiency. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?

Correct Answer is A

Explanation

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?

A nurse is teaching a client how to check their radial pulse. Which of the following methods uses the psychomotor domain of learning?

A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of nociceptive pain?

When measuring the size, depth, and wound tunneling of a client's stage IV pressure injury, what action should the nurse perform first?

A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

A nurse is planning care for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to initiate?