When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

Ask the client if he knows the year he married his wife.

Determine if the client can recall what he ate for breakfast.

Instruct the client to follow a three-step task.

Tell the client to repeat a series of unrelated numbers.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Asking the client if he knows the year he married his wife assesses long-term memory, not recent memory.
Choice B rationale
Determining if the client can recall what he ate for breakfast assesses recent memory but does not provide a comprehensive assessment.
Choice C rationale
Instructing the client to follow a three-step task assesses the client’s ability to process and remember recent information, providing a more thorough evaluation of recent memory.
Choice D rationale
Telling the client to repeat a series of unrelated numbers assesses short-term memory and attention, not specifically recent memory.

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Correct Answer is A

Explanation

Choice A Rationale: Administeíing oxygen via nasal cannula is the fiíst píioíity in this scenaíio. ľhe client’s oxygen satuíation is 88% on íoom aií, which indicates hypoxemia. Píoviding supplemental oxygen will help impíove the client’s oxygenation and alleviate symptoms of shoítness of bíeath. Ensuíing adequate oxygenation is cíucial to píevent fuítheí íespiíatoíy distíess and potential complications.
Choice B Rationale: Obtaining a sputum cultuíe is impoítant to identify the causative oíganism of the client’s íespiíatoíy infection and guide appíopíiate antibiotic theíapy. Howeveí, this action is not the immediate píioíity. Addíessing the client’s hypoxemia by administeíing oxygen takes píecedence to stabilize the client’s condition.
Choice C Rationale: Administeíing an antipyíetic medication can help íeduce the client’s feveí and impíove comfoít. Howeveí, this is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.
Choice D Rationale: Encouíaging the client to incíease fluid intake is impoítant foí maintaining hydíation and helping to thin íespiíatoíy secíetions. Howeveí, this action is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.

A. Positive Homan’s sign bilaterally. B. 2+ pitting edema of ankles bilaterally. C. Pedal pulses weak and thready. D. Capillary refill in both feet greater than 3 seconds.

Correct Answer is B

Explanation

Choice A rationale
Positive Homan’s sign bilaterally indicates deep vein thrombosis (DVT) but does not directly correlate with swelling.
Choice B rationale
2+ pitting edema of ankles bilaterally is a direct indication of swelling and supports the client’s statement about their feet swelling all the time.
Choice C rationale
Pedal pulses weak and thready indicate poor arterial circulation but do not directly confirm swelling.
Choice D rationale
Capillary refill in both feet greater than 3 seconds indicates poor peripheral perfusion but does not directly correlate with swelling.

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When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia. Exhibits Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

Which assessment finding supports the client statement, “My feet swell all the time?”

Correct Answer is B

Explanation

When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m². Based on this BMI, what should the nurse deduce about this client’s general health?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?