The nurse is preparing to conduct a physical assessment on a client who appears uncomfortable and slightly anxious. Which action is the most appropriate for the nurse to take?

Recommend a psychiatric consult

Proceed with the exam by completing invasive aspects first.

Stay with the client at all times to provide assistance.

Use a relaxed manner and reassure the client as necessary.

Answer and Explanation

The Correct Answer is D

A. Recommending a psychiatric consult is premature and not appropriate for routine anxiety during an assessment.

B. Starting with invasive aspects may increase the client's anxiety. Instead, the nurse should ease the client into the exam.

C. Staying with the client at all times may not be necessary and could make the client feel more uncomfortable.

D. Using a relaxed manner and reassuring the client can help reduce anxiety and make the physical assessment more comfortable.

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Correct Answer is A

Explanation

A. The bell of the stethoscope is used to detect low-pitched sounds such as heart murmurs (S3 and S4).

B. Breath sounds are typically auscultated using the diaphragm of the stethoscope.

C. Normal heart sounds (S1, S2) are best heard using the diaphragm of the stethoscope.

D. Bowel sounds are auscultated using the diaphragm, not the bell.

A. Overweight B. Obese C. Underweight D. Healthy weight

Correct Answer is C

Explanation

A. The overweight category is defined as a BMI between 25 and 29.9.

B. The obese category is defined as a BMI of 30 or above.

C. A BMI below 18.5 is considered underweight, which applies to this client with a BMI of 18.0.

D. A healthy weight category is defined as a BMI between 18.5 and 24.9.

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The nurse is preparing to conduct a physical assessment on a client who appears uncomfortable and slightly anxious. Which action is the most appropriate for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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