A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is reporting pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first?

Complete a mental status exam.

Obtain a blood alcohol level.

Inspect legs for infection or trauma.

Inquire about dietary salt intake.

Answer and Explanation

The Correct Answer is C

A.   The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B.   Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C.   This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D.   While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

Nursing Test Bank

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Correct Answer is C

Explanation

A. This question assesses a client's recent memory, not their judgment.
B. This question assesses a client's knowledge and understanding of animals, not their judgment.
C. This question evaluates a client's judgment by assessing their ability to make sound decisions based on hypothetical situations. It requires the client to consider potential consequences and make a logical inference.
D. This question assesses a client's financial knowledge and decision-making skills, but it doesn't directly evaluate their judgment in a hypothetical situation.

A. 15 lb (6.8 kg) weight loss. B. Diminished appetite. C. Decreased height. D. Lower body mass index (BMI)

Correct Answer is C

Explanation

A. Significant weight loss can be a concern for overall health and may be related to various conditions, including nutritional deficiencies. However, weight loss alone does not specifically indicate the need for bone density screening. It may be a factor in a broader health assessment but is not a direct indicator for bone density measurement.
B. A diminished appetite can affect nutritional intake, which in turn may impact bone health over time. However, diminished appetite itself does not directly suggest a need for a bone density screening unless it leads to significant weight loss or is part of a broader concern about nutritional status affecting bone health.
C. Decreased height is a key indicator that may suggest osteoporosis or significant bone loss. This can be due to vertebral compression fractures, which are common in individuals with osteoporosis. A reduction in height over time can be a direct sign that warrants a bone density screening to assess bone health and risk for fractures.
D. A lower BMI can be associated with lower bone mass and increased risk for osteoporosis, particularly in individuals who are underweight. However, while a low BMI can be a risk factor for osteoporosis, it is not as specific as decreased height for prompting a bone density screening.

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Naxlex Comprehensive Predictor Exams

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

Correct Answer is C

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?

Correct Answer is C

Explanation

The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

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?

When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment?

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?