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:

had anything to eat in the last 24 hours?"

been depressed lately?"

been sleeping well?"

ever had problems with your blood sugar?"

Answer and Explanation

The Correct Answer is D

A. Asking about food intake is relevant but less critical compared to assessing potential hypoglycemia or other acute issues related to blood sugar.
B. Depression can cause expressionless facial affect, but it does not usually cause slurred speech or red conjunctivae, making it a less immediate concern.
C. Sleep disturbances might explain some symptoms, but they do not typically cause the combination of slurred speech and red conjunctivae.
D. The client's symptoms could indicate hypoglycemia or other metabolic disturbances related to blood sugar. Assessing for blood sugar issues is crucial because untreated hypoglycemia can lead to serious complications, making it the priority in this situation.

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Correct Answer is ["A","C","D"]

Explanation

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants
Using a warmed stethoscope helps to avoid discomfort for the patient and ensures better transmission of sound. The bell of the stethoscope is effective for detecting low-pitched sounds such as bowel sounds. Lightly placing the stethoscope over the four quadrants of the abdomen allows for thorough assessment of bowel sounds in each area.
B. Place the stethoscope in the ears with the earpieces pointing towards the ears
While this is a standard practice for proper use of a stethoscope to ensure correct sound conduction, it is not specific to assessing bowel sounds. This action is important for accurate auscultation but does not directly relate to the technique of assessing bowel sounds.
C. Turn the suction off while auscultating
Turning off the nasogastric tube suction is crucial because suction noise can interfere with the assessment of bowel sounds. Clear and accurate auscultation of bowel sounds requires a quiet environment to avoid misinterpretation of sounds. Therefore, it is important to turn off any equipment that might create noise during the assessment.
D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent
Auscultating for a minimum of 5 minutes is essential to confirm the absence of bowel sounds. This extended duration helps in making an accurate assessment, as bowel sounds can be intermittent, and it ensures that transient sounds are not missed. This step is critical before concluding that bowel sounds are absent.
E. Palpate the abdomen before auscultating
Palpating the abdomen before auscultating can alter bowel sounds due to the manipulation of the intestines, potentially leading to inaccurate assessment. It is recommended to auscultate first to avoid affecting the natural bowel sounds before physical examination. Palpation should be done after auscultation to assess for any physical abnormalities or tenderness.

A. Recently had dental surgery B. Adheres to a gluten-free diet C. Takes an oral anticoagulant D. Works in a daycare center

Correct Answer is C

Explanation

A. While dental surgery can result in localized bruising or bleeding, it is unlikely to cause widespread ecchymosis on the trunk and extremities. This finding would not typically require additional follow-up for the cause of ecchymosis unless there were other signs of a bleeding disorder.
B. A gluten-free diet is not associated with increased bruising or bleeding. Therefore, this aspect of the client's history does not necessitate further investigation in relation to the observed ecchymosis.
C. Taking an oral anticoagulant is directly related to an increased risk of bleeding and bruising, which can manifest as ecchymosis. The nurse should follow up on this information to assess the adequacy of anticoagulation and whether the medication dosage needs adjustment or if there is a potential overdose.
D. Working in a daycare center does not correlate with the development of ecchymosis and is not typically associated with any condition that would cause widespread bruising. This does not require further follow-up in the context of the observed skin findings.

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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

Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is C

Explanation

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

Exhibits Nurse analyzes the assessment findings. Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

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While observing a client's face, which assessment finding requires immediate intervention by the nurse?

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After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?