The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

Degree of upper body vasculature observed.

Arm circumference and degree of edema.

Blood pressure and heart rate.

Peripheral sensation and movement of upper extremities.

Answer and Explanation

The Correct Answer is C

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.

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Correct Answer is B

Explanation

A. Increasing fiber intake is generally beneficial for digestive health but alone may not address the client's specific concern regarding colon cancer risk, making this advice too narrow.
B. Discussing family history and early screening options with a primary care provider is crucial, as it can lead to earlier detection and intervention, especially given the family history of colon cancer.
C. The CEA blood test is not routinely used for cancer screening; it is primarily used to monitor treatment response or recurrence, not for predicting the development of cancer.
D. Waiting until the age of 60 to be concerned about colon cancer is not advisable, especially with a family history; proactive discussions about screening should begin earlier based on risk factors.

A. "You may feel some slight tingling in your lower extremities." B. "Paresthesia may occur because of the procedure, but it is only temporary." C. "The needle is placed between the vertebrae, but below where the spinal cord ends." D. "You should report any numbness during the procedure to the physician immediately."

Correct Answer is C

Explanation

A. Informing the patient about possible tingling is not as reassuring and does not directly address their concern about spinal cord damage.
B. While paresthesia can occur, focusing on temporary effects might not alleviate the patient’s primary concern about spinal cord injury.
C. Explaining that the needle is placed below where the spinal cord ends directly addresses the patient’s anxiety about potential damage, providing clarity and reassurance about the safety of the procedure.
D. While it is important for patients to report numbness, this response does not reassure them about the procedure's safety and may increase their anxiety.

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The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

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Naxlex Comprehensive Predictor Exams

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