As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon?

Mental

Physical

Spiritual

Interpersonal

Answer and Explanation

The Correct Answer is A

A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.

B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.

C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.

D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.

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Correct Answer is B

Explanation

A. Anterior chest: While the anterior chest examination is important, axillary palpation is more specific to the breast area.

B. Breasts: Palpation of the axillae is part of the breast examination to check for lymph nodes or masses.

C. Heart: The heart is assessed through auscultation and palpation of the chest, not the axillae.

D. Neck: The neck examination does not typically involve palpation of the axillae.

A. To establish personal rapport with the client B. To identify diseases for which the client may be at risk C. To assess the client's quality of life D. To get to know the client better

Correct Answer is B

Explanation

A. To establish personal rapport with the client: While rapport is important, the primary purpose of asking about family health history is not to build a personal connection.

B. To identify diseases for which the client may be at risk: Family health history helps identify genetic or hereditary conditions that may increase the client’s risk for certain diseases.

C. To assess the client's quality of life: Family health history does not directly assess the client’s quality of life but rather their risk for specific conditions.

D. To get to know the client better: Although understanding family history can help in getting to know the client’s health context, the primary purpose is to assess risk factors.

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Naxlex Comprehensive Predictor Exams

The nurse would palpate the axillae during examination of which area?

Correct Answer is B

Explanation

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?

Correct Answer is B

Explanation

Use of tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma.

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

Data collection occurs where in the nursing process?

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)