The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

A 3-year-old child with fever, rash, and sore throat.

A 45-year-old man with chest pain and diaphoresis for 1 hour.

A 14-year-old girl who is crying because she thinks she is pregnant.

A 20-year-old man with a 3-inch shallow laceration on his leg.

Answer and Explanation

The Correct Answer is B

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

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Correct Answer is A

Explanation

A. Collecting client data to make a professional clinical judgment of the client's overall level of functioning is correct because a nursing health assessment evaluates the client holistically, including physical, psychological, and social aspects of health.
B. While a nursing assessment includes chronic diseases and medications, it is broader than just identifying how a present illness is impacting the client.
C. A step-by-step physical examination is one component of the assessment, but the primary purpose is to make a clinical judgment.
D. Nursing assessments go beyond just implementing provider decisions and focus on patient-centered care.

A. Carbohydrate deficiency B. Vitamin B12 deficiency C. Protein deficiency D. Vitamin A deficiency

Correct Answer is C

Explanation

A. Carbohydrate deficiency can lead to low energy levels and weight loss, but it is not primarily associated with edema, brittle nails, or dry hair.
B. Vitamin B12 deficiency can cause neurological symptoms and anemia, but it does not typically lead to edema or brittle nails.
C. Protein deficiency is correct because it can cause muscle wasting, poor wound healing, thin and dry hair, brittle nails, and edema due to low albumin levels.
D. Vitamin A deficiency is primarily linked to vision problems, dry skin, and an increased risk of infections but does not typically cause edema or brittle nails.

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The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the primary purpose of a nursing health assessment?

Correct Answer is A

Explanation

A client has come into the clinic with complaints of anorexia for one month with a noted 20-pound weight loss in the past six weeks. The nurse notes mild edema to the lower extremities, thin, dry hair, and brittle nails. What deficiency are these findings most likely related to?

Correct Answer is C

Explanation

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

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?

The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?