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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the most appropriate time to perform a testicular self-examination because the scrotum is relaxed and easier to examine after warm water exposure.
B. The testicle is egg-shaped and movable, but it should not feel lumpy. Lumps or abnormal findings should be reported to a healthcare provider.
C. While this advice is helpful, it does not answer the question of when or how to perform the
examination.
D. A monthly exam is generally recommended, not weekly, to detect early signs of testicular cancer.
Correct Answer is B
Explanation
A. While this is useful for clients who know sign language, it's important to first determine the communication method that the client prefers.
B. Each client may have different preferences or needs when it comes to communication, so it’s important to assess their preferred method before taking any further steps.
C. Speaking loudly is not effective and can distort words for those with hearing impairments. The focus should be on clear communication, such as lip-reading or using writing.
D. Facial and hand gestures can be helpful for communication, especially for individuals with hearing impairments. Avoiding them is unnecessary and could hinder understanding.
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