A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

Lack of a bowel movement in 2 days

Difficulty sleeping at night

+3 edema in the ankles.

Blanching erythema in the sacral area

Answer and Explanation

The Correct Answer is D

A.   While this can be uncomfortable and may require attention, it is not typically considered an emergency unless accompanied by severe pain, vomiting, or other concerning symptoms.
B.   Insomnia or difficulty sleeping can significantly impact a person's quality of life, but it is not usually an immediate threat to health.
C.   While it is important to assess and manage the underlying cause, it is not usually an immediate emergency unless it is accompanied by other severe symptoms like shortness of breath or chest pain.
D.   This finding suggests the early stages of pressure ulcer development, which can rapidly progress if not addressed promptly. Immediate intervention is crucial to prevent further tissue damage and complications.

Nursing Test Bank

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Correct Answer is A

Explanation

A. The ballottement test involves pressing on the knee joint to check for the presence of fluid, which can indicate joint effusion.
B. The McMurray test is used to assess for meniscal tears, not for fluid around the patella.
C. The Tinel sign is used to assess for nerve compression, not fluid accumulation.
D. The Phalen test is used to diagnose carpal tunnel syndrome, not to assess for joint effusion.

A. "A good time to examine your testicles is just before you take a shower" B. "The testicle is egg shaped and movable. It feels firm and has a lumpy consistency." C. "If you notice an enlarged testicle or a painless lump, call your health care provider D. “Perform a testicular examination at least once a week to detect the early stages of testicular cancer."

Correct Answer is A

Explanation

A. This is the most appropriate time to perform a testicular self-examination because the scrotum is relaxed and easier to examine after warm water exposure.
B. The testicle is egg-shaped and movable, but it should not feel lumpy. Lumps or abnormal findings should be reported to a healthcare provider.
C. While this advice is helpful, it does not answer the question of when or how to perform the
examination.
D. A monthly exam is generally recommended, not weekly, to detect early signs of testicular cancer.

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A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should use which test to check for large amounts of fluid around the patella?

Correct Answer is A

Explanation

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate

Correct Answer is A

Explanation

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first level priority problem?

A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?

While conducting a cultural health assessment a nurse should include which of the following?