The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

Fingernail pitting present.

Nail care needed.

Capillary refill less than 3 seconds.

Nailbeds pink.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Fingernail pitting present: Fingernail pitting appears as small depressions or pits on the nail surface, often seen in psoriasis. The client's nails in the photo are smooth and intact, showing no signs of pitting, so this option is not accurate.

B. Nail care needed: Nail care would be documented if there were overgrown, broken, dirty, or neglected nails. The nails shown are clean and neatly maintained, meaning nail care is not an immediate need for this client.

C. Capillary refill less than 3 seconds: Capillary refill time measures circulation but is not assessed just by observing nail color. It requires pressing the nail and timing how quickly color returns, which is not part of this static assessment.

D. Nailbeds pink: Pink nailbeds indicate good peripheral circulation and oxygenation. In the photo, the client's nailbeds are visibly pink without cyanosis, discoloration, or pallor, making this the correct documentation of the findings.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:
A. Excess vellus hair: Vellus hair is fine, short, unpigmented hair that covers most of the body. It is not related to hair dye use and would not be a typical finding when assessing the scalp hair of someone who frequently dyes their hair.

B. Receding front hairline: A receding hairline is usually related to hormonal changes, aging, or genetic predisposition rather than the direct effects of frequent hair dyeing. Hair dye may damage hair texture, but it does not typically cause patterned hair loss at the hairline.

C. Fine, thin, limp texture: Fine and limp hair is often linked to factors like genetics, aging, or nutritional deficiencies. While hair dye can weaken hair, the more expected result from repeated chemical exposure is a coarse, dry, and brittle texture rather than a limp appearance.

D. Coarse, dry, brittle texture: Frequent chemical dyeing damages the hair cuticle, leading to dryness, roughness, and increased fragility. Palpating the client's scalp would likely reveal hair that feels coarse and brittle, consistent with the effects of long-term chemical processing.

A. Assist the client to stand at the bedside long enough to observe posture. B. Observe the client's ability to sit upright or unassisted while in the bed. C. Document that posture could not be evaluated due to prescribed bedrest. D. Ask the client to describe normal posture while walking and standing.

Correct Answer is B

Explanation

Rationale:
A. Assist the client to stand at the bedside long enough to observe posture: Assisting the client to stand would violate the bedrest order, which is in place to prevent complications such as increased intracranial pressure or falls following a CVA. Standing could pose unnecessary risks and is not appropriate when safer alternatives are available.

B. Observe the client's ability to sit upright or unassisted while in the bed: Evaluating posture can still be done safely within the constraints of bedrest by assessing how well the client can maintain an upright seated position. This allows the nurse to assess muscle tone, balance, and neurological function without compromising safety.

C. Document that posture could not be evaluated due to prescribed bedrest: Bedrest limits standing or walking, but it does not prevent all forms of posture evaluation. The nurse still has a responsibility to assess posture in ways that align with safety protocols and should not omit this part of the neurological assessment.

D. Ask the client to describe normal posture while walking and standing: Relying on the client's verbal report does not replace direct observation. Objective assessment is necessary for accurate neurological evaluation, especially in post-CVA clients where deficits in muscle control and balance may not be fully recognized by the client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

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)?

The nurse is assessing a client's skeletal muscle movements and strength. Which action should the nurse instruct the client to perform to evaluate prime-mover muscle groups?

Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

While completing a health assessment for a client with peripheral vascular disease (PVD), which assessment technique is most important for the nurse to implement?

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this older adult client?

Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

The nurse is assessing the perianal area of a female client who reports she has chronic constipation and has bright red blood on the toilet paper after having a bowel movement. Which finding should the nurse report to the healthcare provider (HCP) that is most consistent with the client's report?