The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

Assessment of the lower extremities

Assessment of the posterior thorax

Assessment of the abdomen

Assessment of the genitalia and rectum

Answer and Explanation

The Correct Answer is D

Given the traumatic nature of sexual assault and the potential for re-traumatization, the assessment of the genitalia and rectum should be conducted last. This allows the nurse to build rapport with the client, establish trust, and address any immediate concerns or needs before proceeding with a potentially distressing examination.

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Correct Answer is B

Explanation

This question is more focused and directly addresses the reason for the client's current admission. It prompts the client to discuss their chief complaint or presenting symptoms, which is essential information for the nurse to gather during the health history interview.
A. This question is too broad and may overwhelm the client, especially during the initial stages of the health history interview.
C. While discussing the client's feelings about hospitalization is important for providing emotional support and understanding their perspective, this question may not directly promote the discussion of health history data.
D. This question invites the client to share their perspective and provides an opportunity for them to express any immediate health issues or worries they may have. However, it is too broad.

A. Pale yellow urine B. Bradycardia C. Poor skin turgor D. Flat neck veins E. Hypotension

Correct Answer is ["C","D","E"]

Explanation

A. In cases of dehydration, urine output may decrease, resulting in a more concentrated urine that appears darker in color. Therefore, the nurse may expect the urine to be darker in color.
B. Tachycardia is more commonly observed due to dehydration and the body's compensatory mechanisms.
C. Poor skin turgor is a classic sign of dehydration and may be observed in clients with vomiting and diarrhea.
D. Flat neck veins aretypically associated with dehydration. This occurs due to reduced intravascular volume leading to collapse of the veins.
E. Hypotension is commonly associated with dehydration resulting from vomiting and diarrhea. Loss of fluids and electrolytes can lead to decreased blood volume and subsequent hypotension.

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The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

Correct Answer is B

Explanation

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

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