The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

To ensure valid conclusions are made when analyzing data.

To reassess previously detected problems to note any changes.

To determine the need for crisis intervention.

To identify strengths and limitations in lifestyle and health status.

Answer and Explanation

The Correct Answer is B

A. Ensuring valid conclusions when analyzing data is part of the initial assessment rather than the purpose of a partial assessment.
B. Reassessing previously detected problems to note any changes is correct because partial assessments are conducted to monitor the client's progress and detect any new or worsening symptoms.
C. Crisis intervention is not the primary purpose of a partial assessment unless a crisis is evident.
D. Identifying strengths and limitations in lifestyle and health status is a component of the initial comprehensive assessment rather than the partial assessment.

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Correct Answer is B

Explanation

A. Increased urinary output is incorrect because NSAIDs like ibuprofen can cause kidney damage, leading to fluid retention and decreased urine output, not increased output.
B. Increased heart rate is correct. Long-term NSAID use can cause gastrointestinal (GI) irritation and ulcers, which may lead to occult blood loss and anemia. Anemia can result in tachycardia (increased heart rate) as the body compensates for decreased oxygen delivery. C. Decreased heart rate is incorrect because anemia and pain typically cause tachycardia, not bradycardia.
D. Hypoglycemia is incorrect because NSAIDs do not significantly impact blood glucose levels.

A. Drink fluids before and after, but not during, meals B. Sit with the head of the bed at a 45-degree angle during meals C. Thoroughly chew small amounts of food with each mouthful D. Be aware of the possibility of temporomandibular joint pain

Correct Answer is C

Explanation

A. Drinking fluids before and after meals but not during meals is incorrect. Clients with dysphagia may require thickened liquids and should sip fluids as needed to facilitate swallowing.
B. Sitting with the head of the bed at a 45-degree angle is incorrect. Clients with dysphagia should be positioned at a 90-degree angle (fully upright) during meals to reduce the risk of aspiration.
C. Thoroughly chewing small amounts of food with each mouthful is correct. Clients with dysphagia should eat slowly, take small bites, and chew food thoroughly to prevent choking and aspiration.
D. Temporomandibular joint pain is not a common issue associated with dysphagia following a stroke. The primary concern is the risk of aspiration.

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The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

Correct Answer is C

Explanation

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?