A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Perform a head-to-toe physical assessment.

Prepare to collect a vaginal specimen for Papanicolaou smear.

Collect information about the client's activities since surgery.

Conduct a comprehensive review of systems.

Answer and Explanation

The Correct Answer is C

A.   At six weeks post-hysterectomy, a focused assessment that addresses the specific concerns related to the surgery and recovery would be more appropriate. A full physical examination might be too broad for this purpose, although aspects of it might be included if specific issues are identified.
B.   A Pap smear is typically not required during a post-surgical follow-up for a hysterectomy unless there is a specific reason to screen for cervical cancer. In many cases, especially if the hysterectomy was for benign reasons and the cervix was removed, Pap smears might not be necessary.
C.   This approach is highly relevant for a post-surgical evaluation. Gathering information about the client’s activities since surgery helps assess the recovery process, identify any issues or complications, and provide appropriate advice for ongoing care. Activities might include physical activity levels, adherence to post-surgical instructions, any new symptoms, and overall well-being.
D.   A comprehensive review of systems is a thorough approach to identifying any potential issues across various body systems. While this can be useful in some cases, it may be more extensive than necessary for a routine follow-up after a hysterectomy.

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Correct Answer is A

Explanation

A. Instructing the client to close their eyes is crucial during sensory assessments, including temperature testing. This helps ensure that the client does not rely on visual cues to determine the temperature of
the stimuli, allowing the nurse to accurately assess the client’s sensory perception based purely on
touch and temperature differences.
B. Covering the client with a warmed blanket is not necessary for assessing temperature perception. This action could alter the client’s baseline sensory perception by affecting their skin temperature, which could lead to inaccurate results. The sensory assessment requires the client to experience temperature changes directly on their skin without external influences like additional warmth.
C. Darkening the room is not relevant for assessing temperature sensation. Visual impairment (like darkening the room) is not related to sensory nerve function related to temperature perception, and this step does not contribute to an accurate assessment of the client's ability to perceive temperature changes.
D. Measuring the client’s body temperature is not a direct method for assessing their sensory nerve function or temperature perception. While knowing the body temperature might be relevant for other reasons, it does not directly assess how well the client can sense temperature changes on their skin.

A. Multiple varicosities on both thighs. B. Lack of hair growth on both lower legs. C. Stage 2 pressure injury over the left ankle. D. Right calf swelling and tenderness.

Correct Answer is D

Explanation

A. Varicosities, or varicose veins, are dilated veins that appear on the skin and are often associated with venous insufficiency. While they can be symptomatic and require management, they typically do not constitute an immediate medical emergency. Varicosities are generally managed with lifestyle changes, compression therapy, or medical procedures, but they are not usually life-threatening.
B. Lack of hair growth on the lower legs can indicate poor circulation, commonly seen in conditions like peripheral arterial disease (PAD). While it is a concerning finding and suggests potential arterial insufficiency, it is not usually an immediate emergency.
C. A Stage 2 pressure injury is characterized by partial-thickness loss of dermis, presenting as a shallow, open ulcer with a pink wound bed. While it requires attention to prevent progression and manage the wound, it is not an immediate emergency compared to other findings that suggest acute complications.

D. Right calf swelling and tenderness are critical findings that could indicate a deep vein thrombosis (DVT), which is a serious condition where a blood clot forms in a deep vein, usually in the leg. DVT can lead to life-threatening complications such as pulmonary embolism if the clot dislodges and travels to the lungs.

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A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Correct Answer is A

Explanation

When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

During a routine health screening of an adult female, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

While performing a health history the nurse asks the client, "You don't use recreational drugs, do you?" This approach is most likely to elicit which response from the client?

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

The nurse places the diaphragm of a warmed stethoscope on a client's abdomen to auscultate the bowel sounds. Which finding is considered normal?

While obtaining a health history, a client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and his respiratory rate is 14 breaths/minute. What is the best nursing action?