Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

Measure the circumference of the calf.

Grasp skin fold of the posterior forearm.

Check hands for parchment-like appearance.

Press skin over a bony prominence.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Measure the circumference of the calf: Measuring calf circumference is used primarily to assess for deep vein thrombosis (DVT) or edema, not dehydration. It evaluates for swelling but does not give information about the client’s hydration status.

B. Grasp skin fold of the posterior forearm: Checking skin turgor by grasping and gently pulling a fold of skin on the posterior forearm is a standard method to assess for dehydration. Poor turgor, where the skin remains tented, suggests fluid volume deficit and supports a diagnosis of dehydration.

C. Check hands for parchment-like appearance: A parchment-like appearance of the hands is more related to normal aging changes rather than acute dehydration. It reflects thinning of the skin rather than fluid status, and could lead to misinterpretation if used for hydration assessment.

D. Press skin over a bony prominence: Pressing over bony prominences checks for edema or pitting rather than skin elasticity. While edema can coexist with dehydration in complex cases, evaluating turgor is a more direct and sensitive technique for diagnosing dehydration.

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Correct Answer is A

Explanation

Rationale:
A. Heartburn occurs when lying down at night: Lying flat increases intra-abdominal pressure and reduces gravity’s assistance in keeping stomach contents from refluxing into the esophagus. Nighttime heartburn is a classic symptom of gastroesophageal reflux disease (GERD) and is important for the nurse to further assess when evaluating the client’s condition.

B. Small frequent meals cause heartburn to worsen: Small, frequent meals are generally recommended for clients with GERD to reduce gastric distention and minimize reflux episodes. Worsening heartburn after small meals would not be typical and suggests another gastrointestinal issue rather than straightforward reflux.

C. Hyperactive bowel sounds are present in all quadrants: Hyperactive bowel sounds are more commonly associated with gastrointestinal disorders like diarrhea or early bowel obstruction, not GERD. GERD primarily affects the esophagus and upper gastric system without typically altering bowel sound patterns.

D. Bowel movements are light grey and chalky: Light grey or chalky stools indicate possible biliary obstruction or liver dysfunction, not gastroesophageal reflux. GERD symptoms are primarily upper gastrointestinal in nature and do not typically affect the color or characteristics of bowel movements.

A. Leading questions. B. Open ended questioning. C. Closed ended questions. D. Detailed questions about a symptom.

Correct Answer is B

Explanation

Rationale:
A. Leading questions: Leading questions suggest an answer and can bias the client's response. They may prevent the nurse from obtaining an accurate and full description of the sputum’s characteristics, which is critical for assessing pneumonia severity.

B. Open ended questioning: Open-ended questions encourage the client to describe their symptoms in their own words, providing more detailed and accurate information about sputum color, consistency, and quantity. This technique allows for a fuller understanding of the client’s condition.

C. Closed ended questions: Closed-ended questions limit the client's response to a simple "yes" or "no" or brief answer. While useful later for clarifying details, they do not encourage the rich description needed for initial assessment of sputum characteristics.

D. Detailed questions about a symptom: Detailed questioning is appropriate after an initial broad assessment. First, the nurse should use open-ended questions to gather a general description, then proceed with more detailed or specific inquiries based on the client’s initial response.

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Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is B

Explanation

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