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The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

been sleeping well?"

been depressed lately?"

had anything to eat in the last 24 hours?"

ever had problems with your blood sugar?"

None

Answer and Explanation

The Correct Answer is A

Answer: A. "Have you been sleeping well?"

Rationale:

A) "Have you been sleeping well?": Sleep deprivation can lead to symptoms such as an expressionless facial affect, slurred speech, and red conjunctivae. Assessing for sleep patterns is a priority to rule out this common and reversible cause of the client's symptoms. Sleep deprivation can also exacerbate other underlying conditions.

B) "Have you been depressed lately?": While depression could explain the expressionless affect, it does not typically cause slurred speech or red conjunctivae. Depression can be assessed later if other immediate causes are ruled out.

C) "Have you had anything to eat in the last 24 hours?": Poor nutritional intake could contribute to fatigue or weakness but is less likely to cause all the observed symptoms (expressionless affect, slurred speech, and red conjunctivae). This question is important but not the first priority.

D) "Have you ever had problems with your blood sugar?": Blood sugar imbalances, particularly hypoglycemia or hyperglycemia, can cause neurological changes. However, the symptoms described are less specific to blood sugar issues and more indicative of sleep or neurological concerns, making this question less immediately relevant.

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Correct Answer is B

Explanation

A) White blood cell count (WBC): While an elevated WBC count can indicate infection or inflammation, it is not directly related to melena. Melena, which is black, tarry stool, is usually an indication of gastrointestinal bleeding, specifically from the upper GI tract.

B) Hematocrit: Hematocrit is a measure of the proportion of red blood cells in the blood. Monitoring hematocrit is essential in the context of melena because gastrointestinal bleeding can lead to a decrease in red blood cells, causing anemia. Therefore, tracking hematocrit levels helps assess the severity of blood loss and the client's overall oxygen-carrying capacity.

C) Glucose: Blood glucose levels are not directly related to melena. Monitoring glucose is crucial for managing diabetes and other metabolic disorders but does not provide information about bleeding or anemia.

D) Blood urea nitrogen (BUN): While BUN levels can increase with gastrointestinal bleeding due to the breakdown of blood proteins in the gut, it is not the primary test to monitor for the effects of bleeding. Hematocrit is more directly indicative of blood loss.

A. Expected finding. B. Cardiac enlargement. C. Benign variation. D. Cardiac atrophy. E. None F. None

Correct Answer is B

Explanation

Rationale:

A. An area of dullness extending from the 2nd to the 5th intercostal space along the left sternal border is an expected finding during a physical examination. This dullness represents the precise anatomical location of the myocardial mass beneath the chest wall, where it displaces resonant lung tissue. Because the heart is a solid organ, it produces a flat, thud-like sound compared to the hollow resonance of the surrounding lobes.

B. Cardiac enlargement, or cardiomegaly, would be indicated if the area of dullness extended lateral to the midclavicular line or shifted significantly downward. In such cases, the displaced apex would reflect ventricular hypertrophy or dilation, typically seen in chronic heart failure. Since the dullness described in the question remains within the standard 2nd to 5th intercostal boundaries, it does not suggest a pathological increase in heart size.

C. A benign variation usually refers to anatomical anomalies like dextrocardia or situs inversus, which would alter the location of dullness to the right side of the thorax. The findings provided describe a perfectly centralized and standard cardiac silhouette on the left side of the mediastinum. Therefore, characterizing this as a variation is incorrect, as it perfectly aligns with the standard clinical baseline for a healthy adult.

D. Cardiac atrophy involves a reduction in myocardial muscle mass and overall heart volume, which would likely result in a smaller area of dullness than described. This condition is often associated with severe wasting diseases or advanced aging and would cause the borders of cardiac dullness to recede inward. The measurement from the 5th up to the 2nd intercostal space represents a robust, normal heart size rather than a diminished or atrophied state.

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The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is B

Explanation

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

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