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. Changes in size, color, and shape of a mole or spot, especially with the development of a bump, could be indicative of skin cancer, particularly melanoma.
B. That there is nothing to be concerned about. Given the changes in the spot's appearance, this is a concerning sign and requires further investigation, so this choice is not correct.
C. Wounds typically heal without such significant color and shape changes, so this is unlikely to be a normal healing process.
D. A secondary lesion is caused by trauma or infection, but the described changes are more concerning for a potential primary skin malignancy, such as melanoma.

A. Determine the cause of current health problems B. validate current symptoms C. Identify current and past health problems D. identify actual health problems

Correct Answer is C

Explanation

A. A review of systems helps assess overall health and symptoms, but it may not always pinpoint the cause directly.
B. While this may be a part of the review of systems, the primary purpose is broader—identifying both current and past health problems.
C. The review of systems is designed to gather information on both current and past health problems, helping to form a comprehensive health history.
D. This is part of the process but is too narrow compared to identifying both current and past health concerns.

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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

A client tells a nurse that "this dark spot on my left shoulder has gotten bigger, changed from a reddish to a brownish color, and used to be flat but is now like a small bump." The nurse knows that these findings may suggest

Correct Answer is A

Explanation

A nurse is interviewing a client in order to obtain a comprehensive health history. The purpose of a review of systems in the health history is to

Correct Answer is C

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?

A nurse is interviewing a male client who has a hearing impairment. What techniques would be most beneficial in communicating with this client?

While conducting a cultural health assessment a nurse should include which of the following?

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Which of the following would be considered an expected finding when assessing accommodation in an adult client?

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