The nurse has been assigned to care for a 62 year-old man. After introducing herself to the patient and explaining that she will be performing a nursing assessment, what is the first area to be assessed after taking vital signs?
assess for level of consciousness and orientation
check for pitting edema
assess the skin
listen to lung sounds
The Correct Answer is A
A. Assess for level of consciousness and orientation – Level of consciousness (LOC) and orientation are crucial in evaluating neurological status, overall health, and potential signs of deterioration. This assessment provides immediate information about the patient’s cognitive function and responsiveness.
B. Check for pitting edema – Assessing for pitting edema is important but is not the first priority unless the patient has signs of fluid overload or heart failure.
C. Assess the skin – Skin assessment is essential but should be performed after ensuring the patient's neurological stability.
D. Listen to lung sounds – While lung auscultation is an important part of the assessment, it follows after assessing consciousness and orientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Apnea – Apnea refers to the temporary cessation of breathing, not rapid breathing.
B. Orthopnea – Orthopnea is difficulty breathing while lying flat, not an increased respiratory rate.
C. Dyspnea – Dyspnea is the sensation of difficult or labored breathing, not necessarily rapid breathing.
D. Tachypnea – Tachypnea is an abnormally fast respiratory rate, often seen in conditions like fever, anxiety, or respiratory distress.
Correct Answer is D
Explanation
A. Percussion – Percussion involves tapping the body to assess underlying structures, not feeling for texture or consistency.
B. Auscultation – Auscultation is listening to body sounds (e.g., heart, lungs, and bowels) using a stethoscope, not feeling structures.
C. Inspection – Inspection is visual observation, not a tactile assessment.
D. Palpation – Palpation involves using the hands to assess the texture, size, consistency, and location of body structures, such as organs or lymph nodes.
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