The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Consult clinical resources explaining the client's diagnosis

Perform a mini overview of the client's body systems.

Obtain and organize materials you will need for the assessment.

Review client's medical record

Answer and Explanation

The Correct Answer is D

A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.

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Correct Answer is A

Explanation

A. Oral mucosa is correct. Central cyanosis occurs when oxygen saturation is significantly reduced and is best assessed in areas with rich vascular supply, such as the oral mucosa, lips, and tongue.
B. Palms are incorrect because peripheral cyanosis (often due to cold exposure or poor circulation) can cause blue-tinged extremities, but this does not indicate central cyanosis.
C. Sclera is incorrect because cyanosis does not affect the sclera; however, jaundice does.
D. Nail beds are incorrect because, like the palms, they are more indicative of peripheral cyanosis, which can result from localized poor perfusion rather than central oxygenation problems.

A. To ensure valid conclusions are made when analyzing data. B. To reassess previously detected problems to note any changes. C. To determine the need for crisis intervention. D. To identify strengths and limitations in lifestyle and health status.

Correct Answer is B

Explanation

A. Ensuring valid conclusions when analyzing data is part of the initial assessment rather than the purpose of a partial assessment.
B. Reassessing previously detected problems to note any changes is correct because partial assessments are conducted to monitor the client's progress and detect any new or worsening symptoms.
C. Crisis intervention is not the primary purpose of a partial assessment unless a crisis is evident.
D. Identifying strengths and limitations in lifestyle and health status is a component of the initial comprehensive assessment rather than the partial assessment.

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The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

Correct Answer is A

Explanation

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

Correct Answer is B

Explanation

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