A nurse is documenting the findings of a head-to-toe assessment on a newly admitted client.
Which of the following information should the nurse include in the documentation?
The client's vital signs are within normal limits.
The client's skin is warm, dry, and intact.
The client's bowel sounds are present in all four quadrants.
All of the above.
The Correct Answer is D
Rationale: The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client's health status.
Incorrect options:
A) The client's vital signs are within normal limits. - This is a correct statement, but it is not the only information that should be documented.
B) The client's skin is warm, dry, and intact. - This is a correct statement, but it is not the only information that should be documented.
C) The client's bowel sounds are present in all four quadrants. - This is a correct statement, but it is not the only information that should be documented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Inspection, auscultation, percussion, palpation
Rationale: The correct order of techniques for abdominal assessment is inspection, auscultation, percussion, and palpation. This order prevents altering bowel sounds by manipulating the abdomen before listening to them.
Incorrect options:
A) Inspection, palpation, percussion, auscultation - This order may alter bowel sounds by palpating and percussing before auscultating them.
C) Auscultation, inspection, palpation, percussion - This order may miss visual cues by inspecting after auscultating.
D) Palpation, auscultation, inspection, percussion - This order may alter bowel sounds and miss visual cues by palpating before auscultating and inspecting.
Correct Answer is D
Explanation
D) The client has an elevated troponin level in the blood.
Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.
A) The client has a history of hypertension and diabetes. - This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.
B) The client rates the pain as 8 on a scale of 0 to 10. - This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.
C) The client has crackles in the lower lobes of both lungs. - This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.