The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae.

Which querry should the nurse ask first?

Have you been sleeping well?

Have you ever had problems with your blood sugar?

Have you had anything to eat in the last 24 hours?

Have you been depressed lately?

Answer and Explanation

The Correct Answer is A

Choice A rationale
Assessing the client's sleep patterns can help determine if fatigue or lack of sleep might be contributing to their symptoms of expressionless facial affect, slurred speech, and red conjunctivae. Poor sleep can lead to various physical and cognitive issues that might explain the client's current presentation.
Choice B rationale
Asking about blood sugar issues is also important, but it might not be the first question to ask given the symptoms. Blood sugar imbalances can cause slurred speech and altered mental status, but it's more common to address general factors like sleep first.
Choice C rationale
Asking if the client has had anything to eat in the last 24 hours is relevant for assessing nutritional status and potential hypoglycemia, but it may not provide immediate insight into the underlying cause of the symptoms.
Choice D rationale
Asking if the client has been depressed lately is important for assessing mental health, but it may not directly address the immediate physical symptoms the client is experiencing.

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Correct Answer is A

Explanation

Choice A rationale
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, the nurse should continue with the remainder of the client’s physical assessment.
Choice B rationale
Reporting the client’s lung sounds to the healthcare provider is unnecessary because vesicular breath sounds are normal and do not indicate any abnormality.
Choice C rationale
Asking the client to cough and then auscultate at the site again is not required since vesicular breath sounds are normal and do not indicate any need for further immediate assessment.
Choice D rationale
Measuring the client’s oxygen saturation with a pulse oximeter is not necessary in this context because the vesicular breath sounds indicate normal lung function.

A. Painful symptoms alleviated by warmth. B. Cool, pale skin below the knees. C. Decreased pain when legs are elevated. D. Deep, continuous pain in the calf muscles.

Correct Answer is C

Explanation

Choice A rationale
Painful symptoms alleviated by warmth are more indicative of conditions such as arthritis or muscle strain rather than venous insufficiency.
Choice B rationale
Cool, pale skin below the knees is more indicative of arterial insufficiency rather than venous insufficiency.
Choice C rationale
Decreased pain when legs are elevated is a common symptom of venous insufficiency. Elevating the legs helps reduce venous pressure and alleviate symptoms such as swelling and aching.
Choice D rationale
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

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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 querry should the nurse ask first?

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Naxlex Comprehensive Predictor Exams

While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Correct Answer is C

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

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?

During an admission assessment, which approach should the nurse use to assess a client’s speech patterns?

The nurse examines a client’s right great toe. The joint is red, edematous, and very painful with limited range of motion. The client’s serum uric acid levels are elevated. Which action should the nurse tell the client to make?

While performing a physical assessment, the nurse is unable to palpate the client’s pedal pulses. Which action should the nurse take?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

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

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae.

Which querry should the nurse ask first?