A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

Lack of a bowel movement in 2 days

Difficulty sleeping at night

+3 edema in the ankles.

Blanching erythema in the sacral area

Answer and Explanation

The Correct Answer is D

A.   While this can be uncomfortable and may require attention, it is not typically considered an emergency unless accompanied by severe pain, vomiting, or other concerning symptoms.
B.   Insomnia or difficulty sleeping can significantly impact a person's quality of life, but it is not usually an immediate threat to health.
C.   While it is important to assess and manage the underlying cause, it is not usually an immediate emergency unless it is accompanied by other severe symptoms like shortness of breath or chest pain.
D.   This finding suggests the early stages of pressure ulcer development, which can rapidly progress if not addressed promptly. Immediate intervention is crucial to prevent further tissue damage and complications.

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Correct Answer is A

Explanation

A. The whispered voice test is used to assess the function of Cranial Nerve VIII, which is responsible for hearing and balance. The nurse's whisper tests the auditory function of this nerve.
B. The vagus nerve is involved in swallowing, voice production, and parasympathetic functions but is not assessed by whispering.
C. This nerve controls lateral eye movement, and a whispered voice test does not assess eye movement.
D. This nerve also controls eye movement, specifically the superior oblique muscle, and is not evaluated by the whispered voice test.

A. When asking if the client took his medications this morning B. When determining if the client is eating a well-balanced diet C. When asking the client about his receptiveness to the transfer D. When asking the client how he completes his ADLS

Correct Answer is A

Explanation

A. Closed-ended questions are useful for obtaining specific information, such as whether the client took their medication. Yes/no responses provide clarity and a quick assessment of adherence.
B. When determining if the client is eating a well-balanced diet. Open-ended questions would be more appropriate here to gather detailed information about the client’s dietary habits.
C. When asking the client about his receptiveness to the transfer. Open-ended questions would be better for understanding the client's feelings about the transfer, as they allow the client to express their thoughts fully.
D. When asking the client how he completes his ADLs. Open-ended questions allow clients to describe their ability to perform activities of daily living, which provides a more comprehensive view of their functional abilities.

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A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

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Naxlex Comprehensive Predictor Exams

The nurse stands behind the client and whispers "5-B-6." This technique is used to assess which of the following Cranial Nerves?

Correct Answer is A

Explanation

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?

Correct Answer is A

Explanation

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve 11?

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the……..lobe.

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate

During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects:

A nurse needs to obtain anthropometric measures of an 80-year-old client. Which of the following statements is true regarding this situation?