A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Motor impairment

Pain

The client's culture

Hearing loss

Answer and Explanation

The Correct Answer is B

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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Correct Answer is A

Explanation

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

A. "Would it help to discuss your feelings about this hospitalization?" B. "What brought you to the hospital?" C. "Would you tell me about all of your medical issues?" D. "Do you want to talk about your health concerns?"

Correct Answer is B

Explanation

A. Asking "Would it help to discuss your feelings about this hospitalization?" is more closed and may not effectively promote discussion about the client's health history.

B. Asking "What brought you to the hospital?" is an open-ended question that allows the client to provide a comprehensive answer and facilitates a meaningful discussion about their health and hospitalization.

C. "Would you tell me about all of your medical issues?" is too broad and could overwhelm the client. A more specific question would be more effective.

D. "Do you want to talk about your health concerns?" is a yes/no question and may not encourage open communication.

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A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

Correct Answer is B

Explanation

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?