Which nutritional data obtained from a client needs MOST validation by a nurse?

"I do not eat salty foods and snacks

"My rings are not fitting on my fingers like they usually do"

"I exercise about 20 minutes a day by walking"

"High blood pressure is present in my mother & grandmother"

Answer and Explanation

The Correct Answer is B

A) "I do not eat salty foods and snacks": This statement indicates the client's dietary habits and, while it can impact overall health, it does not necessarily require immediate validation unless there is reason to doubt its accuracy or it is related to a specific health concern being addressed.

B) "My rings are not fitting on my fingers like they usually do": This statement suggests a change in the client's physical condition, likely indicating fluid retention or edema. This symptom requires validation as it could signify an underlying issue such as heart failure, kidney problems, or other medical conditions that need prompt attention.

C) "I exercise about 20 minutes a day by walking": This statement reflects the client's physical activity routine. While it's important for assessing overall health and fitness, it does not demand immediate validation unless related to a specific health issue.

D) "High blood pressure is present in my mother & grandmother": This statement provides valuable family history information, which is important for assessing genetic risk factors. However, it does not require urgent validation compared to physical changes indicating potential health problems.

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Correct Answer is C

Explanation

A) Intercostal spaces:

Assessing intercostal spaces typically involves palpating or inspecting the area between the ribs to check for abnormalities such as retractions or tenderness, usually conducted with the client sitting or standing.

B) Lymph nodes:

Palpation of lymph nodes, such as in the cervical region, involves using fingertips to gently feel for enlarged or tender nodes. This examination focuses on areas like the neck, underarms, and groin.

C) Skin Turgor:

The image depicts a nurse pinching the skin, likely on the chest or forearm, which is a common method to assess skin turgor. Skin turgor evaluation helps determine hydration status; if the skin remains tented and returns slowly to its original position, it indicates dehydration.

D) Carotid Pulse:

Assessing the carotid pulse involves palpating the carotid artery along the side of the neck to evaluate the strength and rhythm of the pulse. This is typically done using the pads of the fingers, not by pinching the skin.

A. Assess the nasolacrimal sac B. Test pupillary reaction to light C. Inspect the palpebral conjunctiva D. Perform the eye positions test

Correct Answer is A

Explanation

A) Assess the nasolacrimal sac: Excessive tearing, or epiphora, can result from an obstruction in the nasolacrimal duct, which drains tears from the eye into the nasal cavity. By assessing the nasolacrimal sac, the nurse can determine if there is any blockage or infection causing the excessive tearing, making this the most appropriate next step.

B) Test pupillary reaction to light: While testing pupillary reaction to light is important in a comprehensive eye exam, it does not directly address the issue of excessive tearing. This test is more focused on evaluating neurological function and overall eye health.

C) Inspect the palpebral conjunctiva: Inspecting the palpebral conjunctiva can help identify inflammation, infection, or foreign bodies that may cause discomfort or tearing. However, it does not specifically address the cause of excessive tearing related to nasolacrimal duct obstruction.

D) Perform the eye positions test: The eye positions test assesses extraocular muscle function and cranial nerve integrity. While it is important for a complete eye examination, it is not directly related to the symptom of excessive tearing, which is more likely due to issues with tear drainage.

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Which nutritional data obtained from a client needs MOST validation by a nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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