A nurse is caring for a 36-year-old male client on a medical-surgical unit.

Based on the client’s current status, which should the nurse include in a focused assessment?

Observe the client’s respirations for rate, rhythm, and depth

Inspect the skin and mucus membranes

Measure the apical pulse for 60 seconds

Auscultate chest

Have the client demonstrate use of the incentive spirometer

Determine the heart rhythm

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale: Observing respirations for rate, rhythm, and depth is crucial in pneumonia management as respiratory compromise may develop rapidly. Changes in respiratory pattern such as tachypnea, irregular rhythm, or shallow breaths can indicate worsening lung function, hypoxia, or impending respiratory failure, requiring immediate intervention.

Choice B rationale: Inspecting skin and mucous membranes helps assess for signs of hypoxia or poor perfusion, such as cyanosis or pallor. These findings can indicate inadequate oxygen delivery due to impaired lung function in pneumonia. Monitoring skin integrity is also important for infection control and early detection of complications.

Choice C rationale: Measuring the apical pulse for 60 seconds is important in cardiac assessments, especially if arrhythmias or murmurs are suspected. However, in pneumonia without cardiac symptoms or abnormal heart sounds, continuous assessment of apical pulse is not prioritized in a focused respiratory assessment.

Choice D rationale: Auscultating the chest is essential to evaluate breath sounds for signs of consolidation, crackles, or diminished air entry, which directly reflect pneumonia severity and progression. Regular auscultation helps guide treatment decisions and detect complications like pleural effusion or pneumothorax.

Choice E rationale: Having the client demonstrate incentive spirometer use ensures proper technique, promoting lung expansion and preventing atelectasis. Correct use reduces pulmonary complications and supports recovery, making it an important part of nursing assessment and education in pneumonia care.

Choice F rationale: Determining heart rhythm is important in cardiac assessments, but in the absence of arrhythmia symptoms or abnormal ECG findings, it is not a primary focus in pneumonia care. Monitoring vital signs regularly is sufficient unless clinical indications suggest otherwise.

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Correct Answer is B

Explanation

Choice A rationale

Measuring capillary glucose provides information about current blood sugar levels, which is crucial for managing diabetes. However, shiny, hairless lower legs are indicative of chronic peripheral arterial disease (PAD), a microvascular complication, and while hyperglycemia contributes to PAD, a single glucose reading doesn't directly assess arterial perfusion.

Choice B rationale

Shiny skin and absent hair growth on the lower legs are classic signs of peripheral arterial insufficiency, indicating reduced blood flow to the extremities. Palpating the dorsalis pedis pulses directly assesses the patency and strength of peripheral arteries, providing objective data on arterial perfusion and supporting the suspicion of compromised circulation. Normal pulses are usually palpable and regular.

Choice C rationale

Asking about weakness or hunger relates to symptoms of hypoglycemia or hyperglycemia, which are acute metabolic imbalances in diabetes. While important for overall diabetic management, these symptoms do not directly assess the vascular integrity or perfusion status of the lower extremities, which is indicated by the observed skin and hair changes.

Choice D rationale

Comparing the range of motion of both legs assesses joint mobility and musculoskeletal integrity. While diabetes can lead to musculoskeletal complications like stiff joints, this assessment does not directly address the vascular changes (shiny skin, hair loss) that are indicative of impaired arterial blood flow to the lower limbs.

A. Offer to teach a family member how to monitor the skin around the mole. B. Ask the client if he often spends time outside in the sun without a shirt. C. Advise the client to see his healthcare provider (HCP) for immediate evaluation. D. Encourage the client to keep checking the mole with a magnifying mirror.

Correct Answer is C

Explanation

Choice A rationale

While monitoring moles is important, teaching a family member how to do so is a secondary action. The client's report of recent changes—color alteration from brown to black and enlargement—are classic "ABCDE" warning signs of melanoma. Immediate professional evaluation is paramount to rule out or confirm malignancy and initiate prompt treatment.

Choice B rationale

While sun exposure is a significant risk factor for skin cancer, asking about past sun exposure does not address the immediate concern of a rapidly changing mole. The priority is to assess the current lesion for malignancy, which requires a healthcare professional's expertise. Historical information is valuable but not the most urgent action.

Choice C rationale

The reported changes in the mole (change in color from brown to black and enlargement) are highly suspicious for melanoma, a serious form of skin cancer. Immediate evaluation by a healthcare provider (HCP), typically a dermatologist, is crucial for timely diagnosis and potential intervention. Delaying evaluation could significantly impact the prognosis if it is malignant.

Choice D rationale

Encouraging the client to self-monitor with a magnifying mirror delays professional assessment of potentially cancerous changes. Self-monitoring is useful for identifying new or changing lesions, but once concerning changes are noted, professional evaluation is required. A magnifying mirror cannot provide a definitive diagnosis or assess deeper tissue involvement. .

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A nurse is caring for a 36-year-old male client on a medical-surgical unit. Based on the client’s current status, which should the nurse include in a focused assessment?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a 36-year-old male client on a medical-surgical unit.

Based on the client’s current status, which should the nurse include in a focused assessment?