The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)

Tachypnea

Temperature

Turgor

Tympany

Answer and Explanation

Correct Answer : B,C

Normal skin temperature for healthy adults ranges between 92.3 and 98.4 Fahrenheit or 33-37 Celsius, far lower than the 98.6 F average core temp. Changes in skin temperature may indicate potential illness or injuries.

To check for skin turgor, the healthcare provider grasps the skin between two fingers so that it is tented up. Commonly the lower arm or abdomen is checked. The skin is held for a few seconds and then released. Skin with normal turgor snaps rapidly back to its normal position.

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Correct Answer is ["A"]

Explanation

To map the client's abdomen into four quadrants, the nurse should use the umbilicus as the landmark to perform this assessment. The abdomen is divided into four quadrants by drawing an imaginary line from the center of the umbilicus to the pubic symphysis and another line from the center of the umbilicus to the xiphoid process of the sternum. This helps in identifying the location of any potential abdominal discomfort or tenderness.

A. Might choose to get family involved. B. Must contact a physician. C. Might consider referral to social service. D. Are mandated reporters.

Correct Answer is D

Explanation

Nurses are mandated reporters, meaning they are legally required to report any suspected or confirmed cases of child, elder, or vulnerable adult abuse or neglect to the appropriate authorities, such as child protective services or adult protective services. This duty applies regardless of whether the abuse or neglect was disclosed by the victim or observed by the nurse.

While nurses may choose to involve family members or refer the individual to social services, these actions do not replace the legal obligation to report abuse or neglect. Failure to report can result in legal and professional consequences for the nurse.

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The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is mapping the client’s abdomen into four quadrants. Which landmarks should the nurse use to perform this assessment? (Select all that apply)

Correct Answer is ["A"]

Explanation

When child, elder, or vulnerable adult abuse or neglect is disclosed, nurses:

Correct Answer is D

Explanation

The nurse is assessing the patients sleep habits. Which of the patients responses indicate a need for the nurse to provide teaching?

The nurse would use which of the following skills first when examining the cardiovascular system of a patient?

When assessing the heart, the nurse inspects and palpitates which of the following?

The nurse auscultates the client’s abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?

The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate?

Some of the factors that negatively aﬀect nutrition in the older adult include which of the following? (Select all that apply)

A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes mellitus. Which of the following medications should the nurse expect to administer?