A mother brings her obese adolescent daughter to the clinic because for the last 6 months her daughter sleeps every day after school, has lost weight, and has not had a period for 3 months. After sending the mother to the waiting room, which assessment is most important for the nurse to implement?

Request a 24-hour dietary recall.

Question her about thoughts of self harm.

Ask the teen if she is sexually active.

Inquire about the use of illicit drugs.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Request a 24-hour dietary recall: Gathering a dietary history can help assess nutritional intake and obesity management. However, given the significant behavioral changes—excessive sleeping, weight loss, and amenorrhea—the immediate concern is not nutrition but potential underlying psychological distress, which requires urgent attention.

B. Question her about thoughts of self-harm: Sudden weight loss, excessive sleep, amenorrhea, and behavioral withdrawal in adolescents can signal depression, which carries a risk for self-harm and suicide. Screening for suicidal ideation is a priority to ensure the teen's immediate safety and determine if emergency intervention is necessary.

C. Ask the teen if she is sexually active: While assessing sexual activity is important, especially with menstrual irregularities, it is secondary in priority compared to assessing for life-threatening psychological conditions. Sexual history can be explored after ensuring the adolescent is not in immediate psychological danger.

D. Inquire about the use of illicit drugs: Substance use can contribute to mood changes, weight loss, and altered sleep patterns, but it is not the primary concern given the combination of depressive symptoms. Safety screening for self-harm or suicidal ideation takes precedence before evaluating for substance abuse.

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Correct Answer is A

Explanation

Rationale:
A. An audible abdominal bruit: An abdominal bruit may indicate turbulent blood flow, often due to an abdominal aortic aneurysm (AAA). Given the client’s report of deep, constant abdominal pain radiating to the back—classic signs of a possible AAA—this finding is critical and must be reported immediately to prevent life-threatening rupture.

B. Hypoactive bowel sounds in all quadrants: Hypoactive bowel sounds suggest slowed intestinal activity, possibly related to pain, ileus, or peritonitis. Although concerning, it is not as immediately life-threatening as a possible vascular emergency indicated by the presence of an abdominal bruit.

C. A bulge over umbilicus when coughing: A bulge during coughing suggests a possible umbilical hernia. While hernias can become serious if strangulated, they typically do not present with constant radiating pain to the back, making this finding less urgent compared to the suspicion of a vascular emergency.

D. Intermittent pain on deep inspiration: Intermittent pain on deep inspiration could suggest pleuritic pain or musculoskeletal issues rather than a primary abdominal pathology causing constant, radiating pain. While it should be documented and further evaluated if persistent, it is less likely to be the most critical finding in a client presenting with severe abdominal pain radiating to the back.

A. Contracture. B. Crepitus. C. Osteopenia. D. Atrophy. E. Kyphosis.

Correct Answer is ["A","D","E"]

Explanation

Rationale:
A. Contracture: Contractures, which are the permanent tightening of muscles, tendons, or ligaments, can be identified visually through inspection. The nurse may notice abnormal positioning of joints or decreased range of motion, indicating underlying musculoskeletal abnormalities.

B. Crepitus: Crepitus refers to a crackling or grating sound felt or heard during joint movement and is best assessed through palpation or auscultation, not inspection. The nurse must touch or listen to the joint to detect crepitus, making it unsuitable for assessment by inspection alone.

C. Osteopenia: Osteopenia is a reduction in bone mineral density that is diagnosed through specialized imaging tests like dual-energy X-ray absorptiometry (DEXA) scans. It is not visible during physical inspection, as bone density changes do not produce obvious external signs without significant fractures.

D. Atrophy: Muscle atrophy, which is the wasting or loss of muscle mass, can be visually identified through inspection. The nurse may observe a noticeable decrease in muscle bulk compared to the opposite side or to expected norms, indicating disuse or neurologic impairment.

E. Kyphosis: Kyphosis, an exaggerated outward curvature of the thoracic spine, can be detected through inspection by observing the client’s posture and spinal alignment. Visual clues such as a hunchback appearance or forward stooping posture are hallmark signs noted during inspection.

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A mother brings her obese adolescent daughter to the clinic because for the last 6 months her daughter sleeps every day after school, has lost weight, and has not had a period for 3 months. After sending the mother to the waiting room, which assessment is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider (HCP)?

Correct Answer is A

Explanation

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible finding(s)? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?

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Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

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