As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon?

Mental

Physical

Spiritual

Interpersonal

Answer and Explanation

The Correct Answer is A

A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.

B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.

C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.

D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.

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Correct Answer is C

Explanation

A. Apparent state of health: This generally reflects overall health rather than specific mental or cognitive status.

B. Facial expression: Facial expression provides insight into mood and emotional state but does not specifically assess consciousness or orientation.

C. Level of consciousness: Being awake, alert, and oriented is directly related to the level of consciousness, which is a key aspect of assessing cognitive and mental function.

D. Posture, gait, motor activity, and speech: These aspects are relevant for physical activity and motor skills, not specifically for consciousness or cognitive orientation.

A. Wheezes B. Rhonchi C. Coarse crackles (rales) D. No sound

Correct Answer is C

Explanation

A. Wheezes: Wheezes are high-pitched sounds usually associated with airway constriction, such as in asthma, not specifically lobar pneumonia.

B. Rhonchi: Rhonchi are low-pitched, snoring sounds associated with secretions in the airways and may be present in pneumonia but are not the most characteristic finding.

C. Coarse crackles (rales): Coarse crackles or rales are bubbling, crackling sounds heard when air moves through fluid in the airways, which is typical in pneumonia due to the presence of alveolar fluid.

D. No sound: Absence of sound is not expected in pneumonia; adventitious sounds like crackles are usually present.

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Naxlex Comprehensive Predictor Exams

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Correct Answer is C

Explanation

A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?

Correct Answer is C

Explanation

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

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