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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.

B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.

C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.

D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.

A. Head and face B. Mouth and throat C. Mental status examination D. Ears

Correct Answer is A

Explanation

A. Head and face: Cranial nerve VII (facial nerve) controls the muscles of facial expression, so its motor function is assessed by examining the movement of the face, such as smiling, frowning, or raising eyebrows.

B. Mouth and throat: While cranial nerve VII does innervate some muscles involved in facial expressions that might affect the mouth, a more comprehensive assessment of its motor function occurs in the head and face region.

C. Mental status examination: This assesses cognitive functions rather than specific motor functions of cranial nerves.

D. Ears: The assessment of cranial nerve VII does not typically involve the ears.

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Naxlex Comprehensive Predictor Exams

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Correct Answer is B

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Correct Answer is A

Explanation

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

Which type of assessment includes a health history and physical assessment?

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?

The nurse who has been assigned to a client on the second shift is assessing a client to evaluate the outcomes identified in the care plan. This nurse is conducting which type of assessment?

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

The nurse is performing the technique shown. What is the nurse assessing?

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?