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

Forearm pronation involves rotating the forearm so the palm faces posteriorly or downward. While a component of upper extremity assessment, it primarily assesses the radioulnar joints and is not the most direct or specific motion for evaluating the integrity and mobility of the wrist joint itself.

Choice B rationale

Hyperextension and palmar flexion are fundamental movements of the wrist joint, directly assessing its range of motion in the sagittal plane. Ecchymosis often indicates soft tissue injury, and evaluating these specific movements helps pinpoint potential ligamentous or bony involvement, guiding subsequent diagnostic steps.

Choice C rationale

Forearm supination involves rotating the forearm so the palm faces anteriorly or upward. Similar to pronation, this movement primarily assesses the radioulnar joints and is not the primary motion used to evaluate the specific flexion and extension capabilities of the carpal bones and wrist ligaments.

Choice D rationale

Plantar flexion is a movement of the ankle joint, referring to the pointing of the toes downward. This motion is completely unrelated to assessing wrist mobility and is an inappropriate assessment for a client presenting with wrist pain and ecchymosis.

A. Request diagnostic laboratory testing for the client. B. Schedule a follow-up appointment in one month. C. Instruct the client in the need to use iodized salt. D. Obtain a dietary consultation for nutrition teaching.

Correct Answer is A

Explanation

Choice A rationale

An enlarged thyroid gland, or goiter, suggests potential dysfunction of the thyroid, which produces hormones essential for metabolism. Requesting diagnostic laboratory testing, such as thyroid-stimulating hormone (TSH), T3, and T4 levels, is crucial to evaluate thyroid function, identify hyperthyroidism or hypothyroidism, and guide appropriate medical management. Normal TSH is 0.4-4.0 mIU/L.

Choice B rationale

Scheduling a follow-up without immediate investigation delays diagnosis and potential treatment for a condition that could significantly impact the client's metabolic health. Thyroid enlargement warrants prompt assessment to determine its underlying cause, which could range from benign hyperplasia to more serious conditions requiring intervention.

Choice C rationale

While iodine deficiency can cause goiter, instructing on iodized salt use without diagnostic confirmation is premature and potentially inappropriate. Other causes exist, and excessive iodine intake can sometimes worsen thyroid conditions or induce dysfunction. A thorough assessment is paramount before recommending dietary changes.

Choice D rationale

Obtaining a dietary consultation is not the primary action for an enlarged thyroid gland. While diet can influence thyroid health, the immediate priority is to assess the gland's function and identify the underlying pathological process through laboratory and possibly imaging studies, before considering nutritional interventions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

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?