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..."

“ever had problems with your blood sugar?"

“been sleeping well?

“ had anything to eat in the last 24 hours?

“been depressed lately?

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Blood sugar levels can impact neurological function, leading to symptoms like slurred speech, but this is less likely to be the immediate cause of the expressionless affect and red conjunctivae. While important, this question may not address the most urgent concern first. client's symptoms.

Choice B Reason:
"Been sleeping well?" Poor sleep could contribute to slurred speech and an expressionless affect. Asking about sleep might help identify if sleep deprivation is contributing to the symptoms.
Choice C Reason:
Not eating could lead to hypoglycemia, which might cause slurred speech, but it is less likely to explain the red conjunctivae and expressionless affect. This question is important but might not address the immediate cause of the symptoms.
Choice D Reason:
Depression could lead to an expressionless facial affect, but it is less likely to explain slurred speech and red conjunctivae. This question addresses one possible cause but doesn't cover the immediate physical symptoms.

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Correct Answer is C

Explanation

Choice A Reason:

Ask about recent abdominal trauma: in this case, the depressed umbilicus is a normal finding, so no further action related to trauma assessment is necessary.

Choice B Reason:

Palpate the area for masses: Palpating the area for masses is a good practice during abdominal assessments. However, in the context of a depressed umbilicus, this finding is not indicative of an abnormal mass. Therefore, palpation is not specifically warranted.

Choice C Reason:

Document the normal finding: Correct! A depressed umbilicus that lies below the surface of the abdomen is considered a normal variation. Documenting this finding ensures accurate and comprehensive assessment documentation.

Choice D Reason:

Observe the midline for scarring: While observing the midline for scarring is relevant in some situations (such as assessing for surgical scars), it’s not directly related to the depressed umbilicus. Therefore, this action is not necessary based on the specific finding described.

A. Assess conjunctival sacs of lower lids for pallor. B. Observe the client's urine for dark orange color. C. Examine client's sclera for icterus. D. Review recent serum bilirubin levels.

Correct Answer is C

Explanation

Choice A Reason:
Assessing conjunctival sacs of lower lids for pallor is incorrect. Pallor of the conjunctival sacs, or inner eyelids, may indicate anemia or decreased blood flow. While it can be a sign of various health conditions, it is not specific to jaundice. Jaundice is characterized by yellowing of the skin and sclerae (the white part of the eyes) due to elevated bilirubin levels in the blood, so assessing for pallor would not directly confirm jaundice.
Choice B Reason:
Observing the client's urine for dark orange color is incorrect. Dark orange urine may indicate concentrated urine or dehydration, but it is not specific to jaundice. Jaundice primarily manifests as yellowing of the skin and sclerae due to elevated bilirubin levels, rather than a change in urine color. While changes in urine color may occur in certain liver conditions, such as obstructive jaundice, it is not the most direct or reliable method to confirm jaundice.
Choice C Reason:
Examining client's sclera for icterus is correct. Icterus, or yellowing of the sclerae (the white part of the eyes), is a classic sign of jaundice. Elevated levels of bilirubin in the blood lead to the yellow discoloration of the sclerae, providing a direct visual confirmation of jaundice. Examining the sclerae for icterus is a quick and reliable method to confirm jaundice during a physical assessment.
Choice D Reason:
Reviewing recent serum bilirubin levels is incorrect. Reviewing recent serum bilirubin levels can provide objective data on bilirubin levels in the blood, which may support the diagnosis of jaundice. Elevated serum bilirubin levels are characteristic of jaundice. While this option provides valuable information, it may not be immediately available during a physical assessment and does not directly confirm jaundice visually, unlike examining the sclerae for icterus.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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