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 C

Explanation

A. This is incorrect, as a patient’s expression of pain can vary significantly based on cultural, emotional, and psychological factors, not just the severity of the injury.
B. This is false. Pain expression is highly individualized and influenced by cultural and personal factors.
C. This is correct. Different cultures and individuals have varied ways of expressing pain, which can affect their pain management.
D. This is not accurate. Cultural norms play a significant role in how individuals tolerate and express pain.

A. Apply pressure to the temporomandibular joint (TM) B. Squeeze the trapezius muscle C. Press hard on the client's sternum D. Gently shake the client's shoulders

Correct Answer is C

Explanation

A. While pressure on the TM joint could stimulate a response, it is not the most appropriate method for provocation of a response in an unconscious or semiconscious client.
B. This action can be used to assess for painful stimuli, but pressing on the sternum is a more effective method for provoking a response in non-responding clients.
C. Applying firm pressure to the sternum, or sternal rub, is an effective technique to stimulate a response from clients who are non-responsive to verbal stimuli.
D. While shaking might be used for awakening a client, it is not as reliable or effective as a sternal rub when assessing neurological response in acute stroke patients.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

Correct Answer is C

Explanation

An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response?

Correct Answer is C

Explanation

During an assessment of the neurological system, a nurse places a key in the hand of a client, and he identifies it as a key. The nurse would describe this finding as

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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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