When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

To allow for the client to focus on the illness

To allow for the client to spend more time with the nurse

To allow the nurse more time to know the client

To develop a plan with interventions that promote health

Answer and Explanation

The Correct Answer is D

A. To allow for the client to focus on the illness: Accurate and complete information is crucial for developing a proper care plan but not directly related to the client’s focus on their illness.

B. To allow for the client to spend more time with the nurse: Accurate information helps in forming a plan but does not necessarily impact the amount of time spent with the nurse.

C. To allow the nurse more time to know the client: While knowing the client is important, the primary reason for accurate information is to develop effective interventions.

D. To develop a plan with interventions that promote health: Accurate and complete assessment information is essential for developing a comprehensive care plan and interventions that address the client’s health needs.

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Correct Answer is D

Explanation

A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.

B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.

C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.

D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.

A. Pulses B. Vibrations C. Fremitus D. Temperature

Correct Answer is A

Explanation

A. Pulses: The finger pads are particularly effective for detecting the presence, strength, and regularity of pulses due to their sensitivity and the ability to apply gentle pressure.

B. Vibrations: Vibrations are best assessed with the ulnar surface of the hand rather than the finger pads.

C. Fremitus: Fremitus, or the vibrations transmitted through the chest wall, is best assessed using the palmar or ulnar surface of the hand.

D. Temperature: Temperature is more effectively assessed using the back of the hand, not the finger pads.

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When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of

Correct Answer is D

Explanation

The nurse is using the finger pads of the hand to palpate a body part. The nurse would best be able to detect which finding?

Correct Answer is A

Explanation

The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? (Select all that apply.)

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

The nurse is assessing a client's cardiovascular status within the comprehensive health history. What should the nurse include in this section of the assessment? (Select all that apply.)

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