While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?

Vital sign abnormalities.

Presence of peripheral edema.

White blood cell (WBC) count.

Sputum characteristics.

Answer and Explanation

The Correct Answer is D

A.   Vital sign abnormalities can provide critical information about the client's overall condition and help determine if there is an acute or chronic issue that needs to be addressed. While important, this assessment might not provide specific details about the cause of the productive cough.
B.   Peripheral edema is often related to cardiovascular or renal issues and might not be directly related to the cause of a productive cough. While edema can provide information about fluid balance and possible heart failure, it does not directly address the specific characteristics or causes of a cough.
C.   A white blood cell count can help determine if there is an underlying infection or inflammatory process. Elevated WBC levels might indicate an infection, which could be a cause of the productive cough. This test is useful for diagnosing conditions like pneumonia or bronchitis but is not as immediately relevant as assessing the sputum characteristics in understanding the nature of the cough.
D.   The characteristics of sputum (color, consistency, presence of blood, etc.) can provide valuable information about the cause of the productive cough. For instance, yellow or green sputum might suggest a bacterial infection, while clear sputum could be associated with viral infections or allergies.

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Correct Answer is A

Explanation

A. In the context of detecting papilledema, "inspection" refers to using an ophthalmoscope to examine the optic disc for swelling. Papilledema, which is swelling of the optic disc due to increased intracranial pressure, can only be observed through this direct examination of the eye’s interior. This technique is the most appropriate and accurate for confirming papilledema as it allows the nurse to visually inspect the optic disc for signs of swelling or other abnormalities.
B. Percussion involves tapping on the body to assess underlying structures and is commonly used in evaluating lung and abdominal sounds. It is not used for assessing the optic nerve or papilledema. Therefore, percussion is not relevant for confirming the presence of papilledema.
C. Palpation involves feeling the body’s surface to assess for abnormalities such as swelling or
tenderness. It is used for evaluating various parts of the body but does not apply to detecting papilledema. Papilledema involves changes to the optic nerve head, which cannot be assessed through palpation.
D. Auscultation involves listening to internal body sounds using a stethoscope, such as heartbeats, lung sounds, or abdominal sounds. This technique is not used to assess the optic disc or detect papilledema. It is not relevant for the diagnosis of conditions affecting the optic nerve.

A. Circulation impaired. B. Paresthesia reported. C. Reports feeling "on fire." D. Inflammation present.

Correct Answer is B

Explanation

A. This term suggests a problem with blood flow, which could potentially cause symptoms such as numbness or tingling. However, it does not specifically address the sensation of burning. Using this term might lead to an incorrect or incomplete assessment of the client's condition.
B. Paresthesia is a term used to describe abnormal sensations in the skin, such as burning, tingling, or prickling. The client's report of a burning sensation in the hands and legs aligns well with the definition of paresthesia. Documenting it as "paresthesia reported" accurately reflects the nature of the symptoms and is a medically precise way to describe the abnormal sensory experience.
C. This documentation uses colloquial language ("on fire") to describe the client's symptoms. While it conveys the intensity of the sensation, it is not a standardized medical term and may not be as clear or useful for clinical documentation.
D. Inflammation refers to the body's response to injury or infection, which often involves redness, swelling, heat, and pain. The term "inflammation" does not specifically describe the sensation of burning reported by the client.

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While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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