An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

Papules.

Wheals.

Fissuring.

Excoriation.

Answer and Explanation

The Correct Answer is B

A. Papules are small, raised, solid lesions, but they are not the typical primary skin lesion in an allergic reaction.
B. Wheals are raised, red, and itchy areas of the skin that appear in response to an allergic reaction, such as from an insect bite. Wheals are a hallmark sign of urticaria (hives) often seen in allergic reactions.
C. Fissuring refers to deep cracks or breaks in the skin, typically seen in conditions like chronic dermatitis or eczema, not in acute allergic reactions.
D. Excoriation involves skin damage caused by scratching and is secondary to itching, not a primary skin lesion of an allergic reaction.

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Correct Answer is ["A","C","D"]

Explanation

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants
Using a warmed stethoscope helps to avoid discomfort for the patient and ensures better transmission of sound. The bell of the stethoscope is effective for detecting low-pitched sounds such as bowel sounds. Lightly placing the stethoscope over the four quadrants of the abdomen allows for thorough assessment of bowel sounds in each area.
B. Place the stethoscope in the ears with the earpieces pointing towards the ears
While this is a standard practice for proper use of a stethoscope to ensure correct sound conduction, it is not specific to assessing bowel sounds. This action is important for accurate auscultation but does not directly relate to the technique of assessing bowel sounds.
C. Turn the suction off while auscultating
Turning off the nasogastric tube suction is crucial because suction noise can interfere with the assessment of bowel sounds. Clear and accurate auscultation of bowel sounds requires a quiet environment to avoid misinterpretation of sounds. Therefore, it is important to turn off any equipment that might create noise during the assessment.
D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent
Auscultating for a minimum of 5 minutes is essential to confirm the absence of bowel sounds. This extended duration helps in making an accurate assessment, as bowel sounds can be intermittent, and it ensures that transient sounds are not missed. This step is critical before concluding that bowel sounds are absent.
E. Palpate the abdomen before auscultating
Palpating the abdomen before auscultating can alter bowel sounds due to the manipulation of the intestines, potentially leading to inaccurate assessment. It is recommended to auscultate first to avoid affecting the natural bowel sounds before physical examination. Palpation should be done after auscultation to assess for any physical abnormalities or tenderness.

A. Eyelids are matted and crusted. B. Face is flushed and diaphoretic. C. Oral mucosa is cyanotic. D. Corneas are jaundiced.

Correct Answer is C

Explanation

A. Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, but this condition is not immediately life-threatening and does not require urgent intervention.
B. A flushed and diaphoretic face may suggest fever, anxiety, or other non-life-threatening conditions, but it does not require immediate intervention compared to cyanosis.
C. Cyanosis of the oral mucosa indicates a lack of adequate oxygenation and is a sign of possible respiratory or circulatory distress. This finding requires immediate intervention to address the underlying cause and restore proper oxygenation.
D. Jaundiced corneas suggest liver dysfunction, but this finding does not indicate an immediate life-threatening situation requiring urgent intervention.

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An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

Correct Answer is C

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?