A nurse performs a head-to-toe assessment on a newly admitted client. Data analysis reveals temperature 100.94°F (38.3°C), blood pressure 82/58 mm Hg, 02 saturation 95% on room air, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, hemoglobin 9 g/dl, and hematocrit 29%. Based on the analysis of the data, which of the following client concerns is a priority?

hypoxia

anemia

hypotension

Pneumonia

Answer and Explanation

The Correct Answer is C

A) Hypoxia: Although the client's oxygen saturation is slightly decreased at 95% on room air, it is not critically low. Hypoxia could be a concern, but it is secondary to other more immediate issues, such as hypotension, that might be causing the low oxygen saturation.
B) Anemia: The client’s hemoglobin and hematocrit levels are low, indicating anemia. While anemia is a significant concern, it does not pose an immediate threat compared to hypotension, which can lead to more severe complications if not addressed promptly.
C) Hypotension: The client’s blood pressure is notably low at 82/58 mm Hg. Hypotension can lead to inadequate perfusion of vital organs and may be a result of or contribute to other issues such as sepsis or significant blood loss. Immediate attention to correcting hypotension is crucial to prevent further complications.
D) Pneumonia: The client presents with symptoms suggestive of pneumonia, including a productive cough, fever, and elevated white blood cell count. While pneumonia is a critical condition that requires treatment, addressing hypotension is a more urgent priority as it directly impacts the client's circulatory stability and overall well-being.

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Correct Answer is A

Explanation

A) Asymmetrical shape: One of the key "ABCD" characteristics of malignant melanoma is asymmetry. Melanomas often have an irregular shape where one half does not match the other, unlike benign moles, which are typically symmetrical. This characteristic helps in distinguishing malignant lesions from benign ones.
B) Diameter less than 6mm: Malignant melanomas are often larger than 6 mm in diameter, especially as they progress. While smaller lesions can still be malignant, a diameter less than 6 mm is not a distinguishing feature for melanoma. Typically, melanomas are identified as growing larger over time.
C) Color is uniform: Malignant melanomas usually exhibit multiple colors or uneven pigmentation rather than uniform color. Uniform color is more characteristic of benign moles. Melanomas can show a mix of colors, including shades of brown, black, and sometimes red or white.
D) Borders well demarcated: Malignant melanoma often has irregular, not well-defined borders. The edges of a melanoma are usually uneven or not clearly defined, unlike benign moles, which typically have smooth, well-demarcated borders.

A. Sigmoid colon B. Appendix C. Right Fallopian Tube D. Ascending Colon E. Right kidney F. Right side of the prostate

Correct Answer is ["B","C","D"]

Explanation

A) Sigmoid colon: The sigmoid colon is located in the Left Lower Quadrant (LLQ) of the abdomen. Therefore, a bulging area in the Right Lower Quadrant (RLQ) would not be associated with the sigmoid colon.
B) Appendix: The appendix is located in the Right Lower Quadrant and is a common site for abdominal masses, especially in cases of appendicitis. A bulging area in the RLQ could very well be related to issues with the appendix.
C) Right Fallopian Tube: The right fallopian tube is located in the RLQ of the abdomen. Conditions affecting the fallopian tube, such as an ectopic pregnancy or tubo-ovarian abscess, could cause a bulging area in this quadrant.
D) Ascending Colon: The ascending colon is also situated in the RLQ. A mass or bulge in this area could be related to conditions affecting the ascending colon, such as colonic obstruction or tumors.
E) Right kidney: The right kidney is located in the upper abdominal area and is more likely to cause tenderness or discomfort in the upper quadrants rather than a bulging mass in the RLQ.
F) Right side of the prostate: The prostate gland is located in the pelvic area, specifically in the male pelvis, and would not typically be associated with a bulging mass in the RLQ of a female patient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

Correct Answer is A

Explanation

During an abdominal examination, the nurse palpates a bulging area in the Right Lower Quadrant of a female patient. The nurse suspects that this mass could be associated with which of the following organs? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

During a respiratory physical assessment, the nurse directs the patient to say and repeat the letter E for the transmitted voice sounds assessment. The nurse by auscultation hears the letter A instead of E. This is known as:

Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what?

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves?