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 D

Explanation

A. A recent Candida infection could affect the nails, but it typically causes nail thickening and discoloration rather than brittle, concave nails.
B. Diabetes mellitus can lead to various nail changes, including thickening and yellowing, but it is not commonly associated with brittle, concave nails.
C. Coronary heart disease may cause changes in the nails due to poor circulation, but it is not specifically linked to brittle, concave nails.
D. Iron deficiency anemia is commonly associated with brittle, concave nails, a condition known as koilonychia. This nail abnormality is a classic sign of iron deficiency and warrants further investigation.

A. Positive Homan's sign bilaterally. B. 2+ pitting edema of ankles bilaterally. C. Capillary refill both feet greater than 3 seconds. D. Pedal pulses weak and thready.

Correct Answer is B

Explanation

A. A positive Homan's sign indicates potential deep vein thrombosis (DVT) but is not a common or reliable indicator for chronic swelling of the feet. Bilateral swelling is less likely related to DVT and more likely to be due to systemic issues.
B. 2+ pitting edema of the ankles bilaterally directly indicates chronic swelling. This finding supports the client's statement of persistent swelling, which is characteristic of fluid retention or systemic issues affecting both feet.
C. Capillary refill greater than 3 seconds may indicate poor peripheral circulation but does not directly assess or confirm chronic swelling of the feet.
D. Weak and thready pedal pulses suggest poor blood flow but are not directly related to the symptom of chronic swelling. They indicate possible circulatory issues rather than swelling alone.

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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:

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

Which assessment finding supports the client statement, "My feet swell all the time?"

Correct Answer is B

Explanation

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

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