Complete the following sentence using the list of options.
Palpation is the assessment technique using the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient.

Palpation is a critical skill for nurses to master for comprehensive patient assessment.

Palpation helps in identifying abnormalities that may not be visible to the naked eye.

This technique involves careful and systematic touching of the body.

Proper palpation technique ensures accurate and thorough physical examinations.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While palpation is a critical skill, this statement does not directly complete the given sentence which defines palpation as a technique. The existing sentence establishes the "what" of palpation, and the completion should elaborate on "how" it's performed or its direct characteristics.

Choice B rationale

Palpation certainly helps identify abnormalities, but this statement describes a benefit or outcome of the technique, not the core method itself as described in the initial sentence. The sentence sets up the physical action, not its diagnostic utility.

Choice C rationale

This choice logically completes the sentence by explaining the *methodology* of palpation, directly following the description of the senses involved and what is being assessed. It specifies that the technique involves "careful and systematic touching of the body," which directly relates to the physical act of assessment.

Choice D rationale

Proper palpation technique ensures accurate examinations, but this statement focuses on the *quality* of the technique rather than describing the technique itself. The initial sentence defines the technique; the completion should expand on its execution, not its outcome. .

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Correct Answer is D

Explanation

Choice A rationale

Reading newsprint at 20 inches assesses near vision, but it is not the standard clinical method for comprehensive visual acuity assessment. While it can provide some insight into the patient's functional near vision, a more precise and standardized tool like a Jaeger card or specific near vision charts are preferred for accurate diagnostic evaluation.

Choice B rationale

The Jaeger card is specifically designed to assess near visual acuity, typically held at 14 inches (35 cm) from the eye. While useful for evaluating reading vision, it does not provide information about distance visual acuity, which is a primary component of a comprehensive eye examination and is assessed using a Snellen chart.

Choice C rationale

The confrontation test assesses peripheral vision, not central visual acuity. It involves the examiner bringing fingers or objects into the patient's field of vision from various directions. While an important part of a complete eye examination to detect visual field defects, it does not quantify the sharpness of central vision.

Choice D rationale

The Snellen chart is the gold standard for assessing distance visual acuity. Positioning it 20 feet away standardizes the testing distance, allowing for accurate measurement of visual acuity as a fraction (e.g., 20/20). This provides a reliable and reproducible measure of central vision, critical for diagnosing and monitoring visual impairments.

A. Assess the client's skin for breakdown. B. Assess the client's respiratory status. C. Assess the client's urinary output. D. Assess the client's abdominal sounds.

Correct Answer is B

Explanation

Choice A rationale

Assessing the client's skin for breakdown is important in general patient care, especially for immobile patients, but it is not a priority assessment directly related to the immediate physiological effects of administering an opioid analgesic like morphine. Skin integrity issues are typically a long-term complication.

Choice B rationale

Morphine, an opioid agonist, binds to mu-opioid receptors in the central nervous system, including the brainstem respiratory centers. This binding causes dose-dependent respiratory depression by decreasing the sensitivity of these centers to carbon dioxide, leading to reduced respiratory rate and depth. Normal respiratory rate is 12-20 breaths/min.

Choice C rationale

Opioids can cause urinary retention by increasing bladder sphincter tone and reducing detrusor muscle contractility, thereby impairing bladder emptying. While monitoring urinary output is important, respiratory depression is a more immediate and life-threatening adverse effect of opioid administration. Normal urinary output is 30-50 mL/hour.

Choice D rationale

Opioids commonly cause gastrointestinal side effects, including decreased gut motility, leading to constipation and reduced bowel sounds. While assessing abdominal sounds is relevant to monitor for ileus, respiratory depression poses a more acute and significant risk to patient safety following opioid administration.

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Complete the following sentence using the list of options. Palpation is the assessment technique using the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess the visual acuity of a patient. How should the nurse proceed?

Correct Answer is D

Explanation

The nurse is preparing to administer an opioid agonist analgesic to the client. Which of the following would be a priority assessment for the nurse to make once she has given the morphine?

Correct Answer is B

Explanation

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Complete the following sentence using the list of options.
Palpation is the assessment technique using the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient.