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 B

Explanation

A. Soft tissue, such as the liver or spleen, typically produces a dull sound on percussion, not a high- pitched musical sound. Soft tissue is more associated with a dullness because it is denser compared to the surrounding air or fluids.
B. Gas in the gastrointestinal tract often produces a musical or high-pitched sound on percussion, known as tympany. This sound occurs because gas is less dense than other abdominal contents and resonates with a high pitch. Tympany is the most common sound heard when percussing over the stomach and intestines.
C. An intestinal mass, depending on its size and location, may produce a dull or a combination of dull and tympanic sounds. However, it is not typically associated with a high-pitched musical sound. Percussion over an intestinal mass would likely be dull rather than musical.
D. A full bladder typically produces a dull sound on percussion, not a musical high-pitched sound. A dull sound indicates the presence of a solid or fluid-filled structure, such as a full bladder.

A. Auscultate all lobes of the client's lungs. B. Place the client in low Fowler's position. C. Administer a respiratory aerosol treatment. D. Provide oxygen at 2 L/minute via face mask.

Correct Answer is C

Explanation

A. Auscultating all lobes of the lungs is an important step in a comprehensive respiratory assessment. It helps the nurse assess the presence and distribution of abnormal breath sounds, such as wheezing, and evaluate the overall condition of the lungs. While this is a crucial part of the assessment process, it is more of a diagnostic step rather than an immediate intervention for managing respiratory distress.
B. Placing the client in a low Fowler's position (45 degrees) can help improve ventilation and comfort, especially if they are experiencing difficulty breathing. However, in the context of audible wheezing and elevated respiratory rate, more immediate interventions to address the underlying issue are typically required.
C. Administering a respiratory aerosol treatment (such as a bronchodilator) is a direct intervention to address wheezing, which is often caused by bronchoconstriction or inflammation. Aerosol treatments can help open the airways and relieve wheezing, making this a priority action for managing the symptoms described.
D. Providing supplemental oxygen can be beneficial if the client is experiencing hypoxia (low blood oxygen levels). However, the need for oxygen should be determined based on the client's oxygen saturation levels and overall clinical picture. While oxygen can support breathing, it does not address the underlying cause of wheezing or the elevated respiratory rate directly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

Correct Answer is B

Explanation

While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths/minute. Which action should the nurse implement?

Correct Answer is C

Explanation

Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

To confirm the presence of steatorrhea, which action should the nurse take?

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?