The nurse is assessing a client in the acute care setting who has had a history of osteoarthritis. The client states that they have been taking ibuprofen four times a day for over five months and their pain continues to be poorly controlled despite all of their efforts. What is another assessment finding the nurse might anticipate for this client?

Increased urinary output.

Increased heart rate.

Decreased heart rate.

Hypoglycemia.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

A. Inflate the blood pressure cuff 30 mmHg above the point where the radial pulse disappears. B. Assist the patient to a standing position for five to ten minutes. C. Palpate the radial artery and place your stethoscope lightly over this area. D. Measure the blood pressure cuff, ensuring that the cuff encircles 60% of the client’s arm.

Correct Answer is A

Explanation

A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

Correct Answer is A

Explanation

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

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?

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?