A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which assessment data is an expected finding?

Report of generalized joint discomfort

Systemic symptoms including elevated temperature

Denial of pruritus

Report of exposure to a skin irritant

Answer and Explanation

The Correct Answer is D

A. Generalized joint discomfort is not commonly associated with contact dermatitis; this condition typically affects the skin locally rather than causing systemic joint symptoms.

B. Systemic symptoms such as elevated temperature are generally not expected with contact dermatitis, as it is usually a localized skin reaction.

C. Pruritus (itching) is a common symptom of contact dermatitis, so denial of pruritus would not be expected.

D. Contact dermatitis often occurs due to exposure to a skin irritant, making a report of such exposure a typical finding in the assessment.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.

B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.

C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.

D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.

E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.

A. Temperature B. Respirations C. Blood pressure D. Heart rate

Correct Answer is D

Explanation

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between 60-100 bpm), so it is important to re-measure to confirm this finding and assess the client's cardiovascular status.

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A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which assessment data is an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

Correct Answer is D

Explanation

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