The nurse knows the importance of assessing vital signs is to:

Evaluate the client's responses to treatment.

Carry out orders from the healthcare provider.

Monitor risks for alterations in health.

Establish a baseline.

Answer and Explanation

Correct Answer : A,C,D

Choice A Reason:
Assessing vital signs is crucial for evaluating the client's responses to treatment. Changes in vital signs can indicate whether the body is responding positively or negatively to a treatment, allowing healthcare providers to adjust care plans accordingly. For example, a decrease in fever after administering antipyretics would suggest the treatment is effective.

Choice B Reason:
While carrying out orders from the healthcare provider is a responsibility of the nurse, it is not the primary reason for assessing vital signs. Vital signs are assessed to inform clinical decisions, not solely to fulfill orders. Therefore, this choice is not correct in the context of the importance of vital sign assessment.

Choice C Reason:
Monitoring risks for alterations in health is another key reason for assessing vital signs. Vital signs can serve as early indicators of health issues, such as the onset of an infection indicated by a rising temperature or cardiovascular problems suggested by changes in blood pressure or heart rate.

Choice D Reason:
Establishing a baseline is essential when assessing vital signs. It provides a reference point for future comparisons, which is important for detecting any deviations from the client's normal range. This helps in identifying potential health issues early and monitoring the progression of known conditions.

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Correct Answer is B

Explanation

Choice A reason:

Diabetes mellitus is not typically associated with pitting edema unless it has led to a comorbid condition such as heart failure or kidney disease. Pitting edema is more commonly associated with fluid retention due to the body's inability to manage fluid balance, which is not a direct consequence of diabetes mellitus itself.

Choice B reason:

Liver disease, particularly cirrhosis, can lead to pitting edema. The liver's inability to produce albumin, a protein that helps maintain oncotic pressure in the blood vessels, and portal hypertension, which is an increase in the blood pressure within the portal vein system, can both contribute to the development of pitting edema.

Choice C reason:

End-stage renal disease can also cause pitting edema due to the kidneys' inability to excrete excess fluid. However, the edema associated with renal disease is often more generalized and not limited to the lower extremities.

Choice D reason:

Colon cancer is not typically associated with pitting edema unless it has metastasized and caused secondary complications that affect the liver or the heart. Pitting edema is not a direct symptom of colon cancer itself.

A. The immunization schedule recommended for the client's age. B. The need for regular mammogram screening to identify breast cancer lesions. C. The need for consistent use of seat belts when in a motor vehicle. D. The impact of annual vision examinations on personal health and safety.

Correct Answer is B

Explanation

Choice a reason:
Immunization schedules are typically considered a part of primary prevention. They are intended to prevent diseases before they occur by using vaccines to provide immunity against infections.

Choice b reason:
Regular mammogram screenings are a form of secondary prevention. They are used to detect breast cancer lesions early before symptoms appear, which can lead to more effective treatment and better outcomes.

Choice c reason:
The consistent use of seat belts is a primary prevention strategy. It is a proactive measure to prevent injuries in the event of a motor vehicle accident.

Choice d reason:
Annual vision examinations can be considered part of secondary prevention if they are used to detect vision problems or eye diseases in their early stages. However, they can also be seen as primary prevention because they help maintain and protect eye health before issues arise.

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The nurse knows the importance of assessing vital signs is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which disease process should a nurse expect to see a patient with the presence of pitting edema?

Correct Answer is B

Explanation

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

Correct Answer is B

Explanation

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

The nurse working in an ophthalmology clinic is preparing to assess a patient's near vision. Which piece of equipment would the nurse use for this assessment?

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?