The nurse is preparing to conduct a physical assessment. Which statement indicates a correct action by the nurse?

Examine tender or painful areas first to help relieve the patient's anxiety.

Organize the assessment to ensure that the patient does not change positions too often.

Perform all examinations from the left side of the bed.

Follow the same examination sequence, regardless of the patient's age or condition.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Examining tender or painful areas first is not recommended. Starting with areas that cause discomfort may increase the patient’s anxiety and limit cooperation during the rest of the assessment. It is generally best to begin with non-tender areas and save painful areas for last.

B. Organizing the assessment to minimize position changes is correct. Efficient sequencing reduces patient fatigue, discomfort, and unnecessary movement, which is especially important for clients who are weak, ill, or have mobility limitations. This demonstrates proper planning and patient-centered care.

C. Performing all examinations from the left side of the bed is incorrect. While some assessments are routinely done from the left side (e.g., cardiac examination), not all examinations require this position. The nurse should adjust based on the system being assessed and the patient’s condition.

D. Following the same examination sequence regardless of age or condition is inappropriate. Assessment techniques should be adapted based on the client’s age, health status, and ability to cooperate. A rigid sequence may not address specific needs or accommodate safety considerations.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Clubbing of the fingernails is a physical sign characterized by enlargement of the distal fingers and a loss of the normal angle between the nail and nail bed. It is most commonly associated with chronic hypoxia, which occurs in conditions such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, congenital heart disease, or interstitial lung disease. Chronic low oxygen levels trigger changes in the soft tissue beneath the nail bed, leading to the clubbed appearance.

B. Dehydration affects fluid balance and skin turgor but does not cause nail clubbing. Signs of acute dehydration include dry mucous membranes, decreased skin turgor, and hypotension, rather than changes in nail morphology.

C. Sinusitis is an acute or chronic inflammation of the sinuses. While it may cause facial pain, nasal congestion, or fever, it does not lead to clubbing of the nails, as it does not chronically affect oxygenation.

D. Iron deficiency anemia may cause koilonychia (spoon-shaped nails), pallor, or brittle nails, but it is not associated with clubbing. Koilonychia presents differently, with thin, concave nails rather than the bulbous enlargement seen in clubbing.

A. Client reports nipple discharge for the past week B. Axillary lymph node enlargement observed C. Skin dimpling noted near the nipple D. Client reports breast tenderness before menstruation E. A 2-cm firm mass palpated in the right breast

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

Explanation

Rationale:

A. Client reports nipple discharge for the past week is subjective because the nurse is relying on the client’s personal report of experiencing discharge. The nurse cannot verify this symptom without direct observation at the time of the assessment, and the timing and description come from the client’s own account.

B. Axillary lymph node enlargement observed is objective data. The nurse can directly observe or palpate the lymph nodes, measure size, and document enlargement. It is a tangible sign that does not rely on the client’s perception.

C. Skin dimpling noted near the nipple is also objective data. The nurse observes the abnormal contour or indentation of the breast skin during examination, which can be verified visually and documented.

D. Client reports breast tenderness before menstruation is subjective because it is based on the client’s personal experience of discomfort or pain, which the nurse cannot measure. Pain and tenderness are classic examples of subjective findings because they rely on the client’s report.

E. A 2-cm firm mass palpated in the right breast is objective data. The nurse can physically feel, measure, and document the mass. This finding is tangible and reproducible on examination.

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The nurse is preparing to conduct a physical assessment. Which statement indicates a correct action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment, the nurse notes clubbing of the client's fingernails. Which condition should the nurse suspect?

Correct Answer is A

Explanation

A nurse is obtaining a breast health history. Which findings represent subjective data? (Select all that apply.)

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

Explanation

A nurse is preparing to inspect the tympanic membrane of an adult client. Which action demonstrates correct technique?

Which of the following is the correct procedure for measuring an adult's blood pressure using a manual sphygmomanometer?

During a general survey, which assessment finding would be the nurse's highest priority to address?

A nurse is obtaining a skin assessment history from a client. Which of the following findings represents subjective data?

When checking a client's capillary refill, the nurse finds that the color returns in 5 seconds. The nurse should understand that this finding indicates which of the following?

A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?

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A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?