A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

"Lungs clear to auscultation bilaterally."

"High school diploma plus 2 years of college."

"Caregiver reliable source of information."

"Menarche at age 13."

Answer and Explanation

The Correct Answer is D

A. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.

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Correct Answer is D

Explanation

A. Observing for increased abdominal girth is important for conditions such as ascites but is not the priority assessment for a suspected abdominal aneurysm.
B. Palpating the abdomen for masses or pulsations is contraindicated in suspected abdominal aneurysms, as it may cause rupture.
C. Auscultating for a friction rub is used for liver or spleen inflammation and is not relevant in this case.
D. Listening with the bell of the stethoscope for vascular sounds is correct because an abdominal aneurysm may produce a bruit, which can be heard over the affected artery. This assessment helps confirm the presence of turbulent blood flow, a key sign of an aneurysm.

A. "You are probably sad about that." B. "Are you feeling sad, depressed, angry, or upset?" C. "How does that make you feel right now?" D. "What was the cause of your wife's death?"

Correct Answer is C

Explanation

A. "You are probably sad about that" assumes the client’s emotions rather than allowing them to express their own feelings.
B. "Are you feeling sad, depressed, angry, or upset?" is a closed-ended question that may limit the client’s ability to fully express emotions.
C. "How does that make you feel right now?" is correct because it is an open-ended question that encourages the client to explore and express their emotions in their own words.
D. "What was the cause of your wife's death?" shifts the focus away from the client’s emotions and may come across as insensitive.

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A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

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Correct Answer is D

Explanation

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

Correct Answer is C

Explanation

A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

A client has come into the clinic with complaints of anorexia for one month with a noted 20-pound weight loss in the past six weeks. The nurse notes mild edema to the lower extremities, thin, dry hair, and brittle nails. What deficiency are these findings most likely related to?

The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?