The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

Groin

Heels

Elbows

Toes

Answer and Explanation

The Correct Answer is A

A. The groin is correct because skin folds in obese clients are prone to excessive moisture, which increases the risk of fungal or bacterial infections such as intertrigo. The nurse should inspect these areas for redness, irritation, or signs of infection.
B. The heels are at risk for pressure injuries but are not typically associated with excessive moisture or diaphoresis.
C. The elbows are not a common site for moisture retention and are not a priority for inspection in this case.
D. The toes can be prone to fungal infections (e.g., athlete’s foot), but the primary concern in an obese client with diaphoresis is the skin folds, particularly in the groin and under the breasts.

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Correct Answer is D

Explanation

A. Reviewing sodium and bicarbonate levels is not the most immediate action. While these lab values may provide useful information, they do not directly assess the suspected condition.
B. Assessing for peptic ulcer disease is incorrect because a tight, distended abdomen with visible arterioles (caput medusae) is more indicative of liver disease, such as cirrhosis or portal hypertension, rather than a gastric ulcer.
C. Assessing the client’s nutritional status may be important, but it is not the priority in this situation. Malnutrition can be a consequence of liver disease, but the nurse should first focus on identifying the underlying condition.
D. Assessing the client for other signs and symptoms of liver disease is correct. A distended abdomen and visible arterioles suggest possible ascites and portal hypertension, both of which are common in liver disease. Further assessment for jaundice, hepatic encephalopathy, or changes in liver enzyme levels would be appropriate.

A. Collect client data in order to make a professional clinical judgment of the client's overall level of functioning. B. Provides information about chronic diseases and medications to identify how a present illness is impacting the client. C. Compile data during a step-by-step physical examination. D. Focuses on the client's physiologic status in order to implement provider decisions.

Correct Answer is A

Explanation

A. Collecting client data to make a professional clinical judgment of the client's overall level of functioning is correct because a nursing health assessment evaluates the client holistically, including physical, psychological, and social aspects of health.
B. While a nursing assessment includes chronic diseases and medications, it is broader than just identifying how a present illness is impacting the client.
C. A step-by-step physical examination is one component of the assessment, but the primary purpose is to make a clinical judgment.
D. Nursing assessments go beyond just implementing provider decisions and focus on patient-centered care.

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The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Correct Answer is D

Explanation

What is the primary purpose of a nursing health assessment?

Correct Answer is A

Explanation

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