The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dyeing my hair for so long, I'm not even sure... I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair?

Excess vellus hair.

Fine, thin, limp texture.

Receding front hairline.

Coarse, dry, brittle texture.

Answer and Explanation

The Correct Answer is D

A. Vellus hair is fine, short, and lightly pigmented hair that covers most of the body. It is not typically associated with the effects of hair dye or chemical treatments. Excess vellus hair would be unusual in this context and is not related to the typical outcomes of hair dyeing.
B. Fine, thin, and limp hair can be a result of chemical damage from hair dyeing and other treatments. Hair that has been subjected to frequent dyeing and chemical processing can lose its strength and texture, becoming weaker and less resilient. This finding is consistent with the impact of repeated hair dyeing.
C. A receding front hairline is typically associated with genetic factors and androgenic alopecia (pattern baldness) rather than the effects of hair dyeing. Although hair loss can be influenced by various factors, including chemicals, a receding hairline is not a direct consequence of dyeing hair.
D. Coarse, dry, and brittle hair is a common result of frequent chemical treatments, including hair dyeing. Chemicals in hair dyes can strip moisture from the hair, leading to a rough texture, breakage, and brittleness. This finding is consistent with long-term use of hair dye and chemical processing.

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Correct Answer is C

Explanation

A. Being oriented x 3 means the client is aware of their name, the current time (or day), and the location (place). In this case, since the client is only able to remember his name and where he is, but not the time, day, or date, this documentation would be incorrect. The client does not meet the criteria for being oriented x 3.
B. Being oriented x 1 means the client is aware of only one aspect of orientation, such as their name. Since the client is able to remember both his name and his location, documenting as oriented x 1 would not fully capture the extent of the client's orientation. The client is oriented to more than one aspect.
C. Being oriented x 2 means the client is aware of two aspects of orientation. In this case, since the client is able to remember his name and his location (but not the time, day, or date), documenting as oriented x 2 accurately reflects his level of orientation.
D. Being oriented x 4 means the client is aware of four aspects: their name, the current time (or day), the date, and the location. Given that the client can only remember his name and location, this
documentation would be incorrect as it does not align with the client’s current state of orientation.

A. Dyspnea. B. Peripheral edema. C. Intercostal retractions. D. Headaches. E. Jugular venous distension.

Correct Answer is ["A","B","E"]

Explanation

A. Dyspnea, or shortness of breath, is a common symptom of heart failure exacerbation. It occurs because the heart is unable to effectively pump blood, leading to pulmonary congestion and fluid accumulation in the lungs. This symptom is significant in confirming an exacerbation of heart failure.
B. Peripheral edema, or swelling of the legs and ankles, is another common sign of heart failure exacerbation. It results from fluid buildup due to the heart's decreased ability to manage blood volume effectively. This finding is indicative of fluid retention and can confirm an exacerbation of heart failure.
C. Intercostal retractions are typically seen in respiratory distress, especially in conditions affecting the lungs or severe respiratory conditions. While they can occur with severe pulmonary congestion in heart failure, they are more directly associated with respiratory issues rather than specifically confirming heart failure exacerbation.
D. Headaches are not a typical or primary symptom of heart failure exacerbation. They can be associated with various conditions but are not specific to heart failure. This symptom is less relevant in confirming an exacerbation of heart failure.
E. Jugular venous distension is a classic sign of right-sided heart failure or fluid overload. It occurs when there is increased pressure in the venous system due to the heart's inability to handle blood volume effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document?

Correct Answer is C

Explanation

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HP? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

During a routine physical examination of a middle-aged female client, chest palpation is determined to be normal except for a 2 inch diameter area of crepitus over the upper right anterior chest. Which is the most accurate interpretation of this finding?

While obtaining a health history, a client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and his respiratory rate is 14 breaths/minute. What is the best nursing action?

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

During a routine health screening of an adult female, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?