A nurse is receiving a patient from the emergency room.

To assess whether a client is having symptoms of abdominal problems, which symptom would the nurse ask the patient? For each data collection, choose whether the assessment is essential or non-essential.

leg pain

indigestion

headache

pruritus of the skin

nausea

vomiting

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Indigestion: This is a common symptom related to abdominal issues, and the nurse should assess it.

Nausea: Often indicates gastrointestinal distress and is important to evaluate.

Vomiting: A critical symptom that can signify a range of abdominal problems and warrants further assessment.

Non-essential:

Leg pain: Not typically associated with abdominal problems, making it non-essential for this assessment.

Headache: While it can be related to many conditions, it is not directly tied to abdominal problems.

Pruritus of the skin: Generally unrelated to abdominal symptoms, making it non-essential for this specific assessment.

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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.

A. Blood pressure 178/90 mm Hg B. Low body temperature C. Jugular vein distention D. Skin tenting present

Correct Answer is D

Explanation

A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.

B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.

C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.

D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.

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A nurse is receiving a patient from the emergency room. To assess whether a client is having symptoms of abdominal problems, which symptom would the nurse ask the patient? For each data collection, choose whether the assessment is essential or non-essential.

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Naxlex Comprehensive Predictor Exams

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

A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Correct Answer is D

Explanation

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A nurse is receiving a patient from the emergency room.

To assess whether a client is having symptoms of abdominal problems, which symptom would the nurse ask the patient? For each data collection, choose whether the assessment is essential or non-essential.