You answer Ms. B's call light just after lunch. She complains of severe abdominal pain. What type of assessment should you perform?

head-to-toe assessment

focused assessment

complete assessment

system-by-system assessment

Answer and Explanation

The Correct Answer is B

A. Head-to-toe assessment – A head-to-toe assessment is a comprehensive evaluation of all body systems and is not appropriate for an urgent complaint.

B. Focused assessment – A focused assessment is used for specific complaints, such as severe abdominal pain, to quickly gather relevant information.

C. Complete assessment –. A complete assessment includes a full health history and physical examination, which is unnecessary in an acute situation.

D. System-by-system assessment – A system-by-system assessment is detailed and comprehensive but may be too broad for addressing an immediate concern.

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Correct Answer is C

Explanation

A. Tachycardia. – Tachycardia refers to a heart rate above 100 beats per minute, not a slow heart rate.

B. Tachypnea. – Tachypnea describes rapid breathing, not a slow heart rate.

C. Bradycardia. – Bradycardia is a heart rate below 60 beats per minute. It may be normal in athletes but can indicate conduction abnormalities or medication effects in other individuals.

D. Apnea. – Apnea is the absence of breathing, not a slow heart rate.

A. Press the skin over the client's ankle bone B. Lightly palpate the skin using the fingertips C. Grasp a fold of skin on the client's forearm or near the sternum D. Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen

Correct Answer is C

Explanation

A. Press the skin over the client's ankle bone. – The skin over bony prominences does not provide an accurate assessment of turgor due to reduced subcutaneous tissue in elderly clients.

B. Lightly palpate the skin using the fingertips. – Light palpation assesses texture and moisture but does not evaluate skin turgor.

C. Grasp a fold of skin on the client’s forearm or near the sternum. – Skin turgor is best assessed by gently pinching the skin on the forearm or sternum. Delayed return to normal indicates dehydration or decreased skin elasticity due to aging.

D. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. – This describes petechiae, which indicate capillary fragility or bleeding disorders, not skin turgor.

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You answer Ms. B's call light just after lunch. She complains of severe abdominal pain. What type of assessment should you perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An abnormally slow heart rate, below 60 beats per minute is called:

Correct Answer is C

Explanation

The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

Febrile is an abnormal elevation of:

The main reason that auscultation precedes palpation of the abdomen is to:

Any disturbance of the structure or function of the body is a pathological condition. This condition is termed a/an:

The study of all factors involved in the development of the disease or the cause of the disease is termed:

When performing a physical examination of the patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness. This technique is:

Auscultation of the heart sounds will result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. The lub part of the sound is caused by the:

The patient was admitted with a complaint of abdominal pain. Later the nurse observed the patient demonstrating dyspnea. This change in condition required an assessment called: