The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

To ensure valid conclusions are made when analyzing data.

To reassess previously detected problems to note any changes.

To determine the need for crisis intervention.

To identify strengths and limitations in lifestyle and health status.

Answer and Explanation

The Correct Answer is B

A. Ensuring valid conclusions when analyzing data is part of the initial assessment rather than the purpose of a partial assessment.
B. Reassessing previously detected problems to note any changes is correct because partial assessments are conducted to monitor the client's progress and detect any new or worsening symptoms.
C. Crisis intervention is not the primary purpose of a partial assessment unless a crisis is evident.
D. Identifying strengths and limitations in lifestyle and health status is a component of the initial comprehensive assessment rather than the partial assessment.

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Correct Answer is B

Explanation

A. Lithotomy position is used for gynecologic, rectal, or urologic exams and would not be comfortable for a client with low back pain.
B. Dorsal recumbent position is correct because it allows the client to lie on their back with knees bent, reducing strain on the lower back while facilitating assessment of the chest, extremities, and peripheral pulses.
C. Sim’s position is used for rectal examinations or enemas and is not ideal for assessing the chest and extremities.
D. Prone position (lying face down) would exacerbate low back pain and make it difficult to examine the chest and extremities.

A. Oral mucosa B. Palms C. Sclera D. Nail beds

Correct Answer is A

Explanation

A. Oral mucosa is correct. Central cyanosis occurs when oxygen saturation is significantly reduced and is best assessed in areas with rich vascular supply, such as the oral mucosa, lips, and tongue.
B. Palms are incorrect because peripheral cyanosis (often due to cold exposure or poor circulation) can cause blue-tinged extremities, but this does not indicate central cyanosis.
C. Sclera is incorrect because cyanosis does not affect the sclera; however, jaundice does.
D. Nail beds are incorrect because, like the palms, they are more indicative of peripheral cyanosis, which can result from localized poor perfusion rather than central oxygenation problems.

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The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

Correct Answer is B

Explanation

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

Correct Answer is A

Explanation

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

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