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The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

been sleeping well?"

been depressed lately?"

had anything to eat in the last 24 hours?"

ever had problems with your blood sugar?"

None

Answer and Explanation

The Correct Answer is A

Answer: A. "Have you been sleeping well?"

Rationale:

A) "Have you been sleeping well?": Sleep deprivation can lead to symptoms such as an expressionless facial affect, slurred speech, and red conjunctivae. Assessing for sleep patterns is a priority to rule out this common and reversible cause of the client's symptoms. Sleep deprivation can also exacerbate other underlying conditions.

B) "Have you been depressed lately?": While depression could explain the expressionless affect, it does not typically cause slurred speech or red conjunctivae. Depression can be assessed later if other immediate causes are ruled out.

C) "Have you had anything to eat in the last 24 hours?": Poor nutritional intake could contribute to fatigue or weakness but is less likely to cause all the observed symptoms (expressionless affect, slurred speech, and red conjunctivae). This question is important but not the first priority.

D) "Have you ever had problems with your blood sugar?": Blood sugar imbalances, particularly hypoglycemia or hyperglycemia, can cause neurological changes. However, the symptoms described are less specific to blood sugar issues and more indicative of sleep or neurological concerns, making this question less immediately relevant.

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Correct Answer is D

Explanation

Answer: D

Rationale:

A) Tenderness:

Tenderness upon palpation is not considered a normal finding. It may indicate inflammation, injury, or other underlying conditions affecting the thoracic region. Tenderness requires further investigation to determine the cause and appropriate treatment.

B) Crepitus:

Crepitus, which is a crackling or popping sensation felt under the skin, is not a normal finding. It can be associated with subcutaneous air or gas, often resulting from trauma or infection. Identifying crepitus prompts further evaluation to determine the underlying issue.

C) Thrill:

A thrill is a palpable vibration or sensation over the chest, typically felt over an area of turbulent blood flow, such as a heart murmur. It is not considered a normal finding in the thoracic region and usually indicates an abnormal cardiovascular condition that requires further assessment.

D) Non-tender:

A non-tender thoracic region is considered a normal finding. Absence of tenderness upon palpation indicates no immediate signs of inflammation or injury in the thoracic area, suggesting that the palpation findings are within the expected range of normal physical examination.

A. Closed ended questions. B. Leading questions. C. Detailed questions about a symptom. D. Open ended questioning.

Correct Answer is D

Explanation

A) Closed ended questions:
Closed-ended questions typically elicit short, specific responses and may not provide comprehensive information about the sputum's characteristics.

B) Leading questions:
Leading questions suggest a particular answer and may bias the client's response, preventing the nurse from obtaining an accurate description of the sputum.

C) Detailed questions about a symptom:
While detailed questions can be useful, they may be too specific initially and might not allow the client to freely describe their sputum in their own words.

D) Open ended questioning:
Open-ended questions encourage the client to provide more detailed and descriptive responses, allowing the nurse to gather comprehensive information about the sputum's color, consistency, amount, and other characteristics. This technique is best for obtaining a thorough and accurate description of symptoms.

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The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Correct Answer is D

Explanation

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is D

Explanation

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