When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

Numeric pain intensity scale.

Apical-radial pulse deficit.

Anteroposterior (AP) chest diameter.

Body temperature.

Answer and Explanation

The Correct Answer is A

A.   The numeric pain intensity scale is a direct and effective method to assess the level of pain a patient is experiencing. If a client is splinting their chest, it’s essential to evaluate their pain level to determine the severity and guide appropriate pain management strategies. This is likely the most relevant and immediate follow-up assessment in this scenario.
B.   An apical-radial pulse deficit measures the difference between the apical pulse (heart rate auscultated at the apex of the heart) and the radial pulse (heart rate palpated at the wrist). This assessment is used to detect conditions such as atrial fibrillation or other arrhythmias and is not directly related to the client’s chest splinting. Therefore, it is not the most relevant follow-up assessment in this context.
C.   The anteroposterior (AP) chest diameter assessment is used to evaluate conditions such as barrel chest, which can be associated with chronic respiratory conditions. While this measurement can be important for assessing chronic respiratory issues, it is not directly related to the immediate concern of chest splinting, which is more likely associated with acute pain or discomfort.
D.   Measuring body temperature is important for assessing the presence of fever or infection, but it does not directly address the client’s immediate complaint of chest pain or discomfort. While an elevated temperature might be relevant if an infection is suspected, it is not the most direct or immediate follow- up assessment for the observed behavior of splinting the chest.

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Correct Answer is C

Explanation

A. At six weeks post-hysterectomy, a focused assessment that addresses the specific concerns related to the surgery and recovery would be more appropriate. A full physical examination might be too broad for this purpose, although aspects of it might be included if specific issues are identified.
B. A Pap smear is typically not required during a post-surgical follow-up for a hysterectomy unless there is a specific reason to screen for cervical cancer. In many cases, especially if the hysterectomy was for benign reasons and the cervix was removed, Pap smears might not be necessary.
C. This approach is highly relevant for a post-surgical evaluation. Gathering information about the client’s activities since surgery helps assess the recovery process, identify any issues or complications, and provide appropriate advice for ongoing care. Activities might include physical activity levels, adherence to post-surgical instructions, any new symptoms, and overall well-being.
D. A comprehensive review of systems is a thorough approach to identifying any potential issues across various body systems. While this can be useful in some cases, it may be more extensive than necessary for a routine follow-up after a hysterectomy.

A. Excess vellus hair. B. Fine, thin, limp texture. C. Receding front hairline. D. Coarse, dry, brittle texture.

Correct Answer is D

Explanation

A. Vellus hair is fine, short, and lightly pigmented hair that covers most of the body. It is not typically associated with the effects of hair dye or chemical treatments. Excess vellus hair would be unusual in this context and is not related to the typical outcomes of hair dyeing.
B. Fine, thin, and limp hair can be a result of chemical damage from hair dyeing and other treatments. Hair that has been subjected to frequent dyeing and chemical processing can lose its strength and texture, becoming weaker and less resilient. This finding is consistent with the impact of repeated hair dyeing.
C. A receding front hairline is typically associated with genetic factors and androgenic alopecia (pattern baldness) rather than the effects of hair dyeing. Although hair loss can be influenced by various factors, including chemicals, a receding hairline is not a direct consequence of dyeing hair.
D. Coarse, dry, and brittle hair is a common result of frequent chemical treatments, including hair dyeing. Chemicals in hair dyes can strip moisture from the hair, leading to a rough texture, breakage, and brittleness. This finding is consistent with long-term use of hair dye and chemical processing.

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When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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