The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem?

Inﬂammation of the lips

Hypoxia

Beginning of a liver blister

Lack of dental care

Answer and Explanation

The Correct Answer is B

Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturation level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips. Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immediate medical attention.

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

Explanation

The nurses would teach the patient to palpate all four quadrants of the breast, including the upper outer quadrant, lower inner quadrant, and upper inner quadrant, as well as the tail of Spence, which is the extension of breast tissue into the axilla (armpit). It's important for the patient to be familiar with their own breast tissue and report any changes or abnormalities to their healthcare provider.

A. Might choose to get family involved. B. Must contact a physician. C. Might consider referral to social service. D. Are mandated reporters.

Correct Answer is D

Explanation

Nurses are mandated reporters, meaning they are legally required to report any suspected or confirmed cases of child, elder, or vulnerable adult abuse or neglect to the appropriate authorities, such as child protective services or adult protective services. This duty applies regardless of whether the abuse or neglect was disclosed by the victim or observed by the nurse.

While nurses may choose to involve family members or refer the individual to social services, these actions do not replace the legal obligation to report abuse or neglect. Failure to report can result in legal and professional consequences for the nurse.

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The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing the breast, the nurse would teach the patient to palpate which of the following areas?

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

Explanation

When child, elder, or vulnerable adult abuse or neglect is disclosed, nurses:

Correct Answer is D

Explanation

The nurse should utilize what type of precaution when palpating the lips in a healthy adult?

Which of the following would be considered an abnormal finding and require prompt follow up when auscultating breath sounds?

The nurse is mapping the client’s abdomen into four quadrants. Which landmarks should the nurse use to perform this assessment? (Select all that apply)

A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?

A patient is admitted to the ﬂoor with a diagnosis of chest pain. Which of the following would be a priority for the assessment?

The nurse is assessing the patient's ear. The correct procedure for straightening the ear canal of an adult is to pull the pinna…

Child maltreatment, sibling violence, bullying, elder abuse, hate crimes and war/combat violence are types of?

The nurse is working at a pain clinic and is preparing orientation for new staﬀ nurses. Which of the following definitions of pain would the nurse correctly choose to include in the orientation?