The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

"What were you doing when you first noticed the problem?"

"Have you taken any medications to relieve the pain?"

"Does changing your position make the pain worse?"

"Do you remember ever having this type of pain in the past?"

Answer and Explanation

The Correct Answer is A

A.   Understanding the onset and activities related to the back pain can help the nurse determine if it is musculoskeletal, posture-related, or indicative of a more serious underlying issue.
B.   Asking about medication is secondary until more information is gathered about the pain's onset and nature.
C.   Changing positions may be relevant later, but initially, it is important to identify any possible triggers for the pain.
D.   Asking about previous pain episodes may be helpful, but understanding the current episode’s cause is more pressing.

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Correct Answer is A

Explanation

A. Skin tenting is a sign of dehydration. It occurs when the skin, after being pinched, does not quickly return to its normal position. This is often seen in areas with loose skin such as the subclavicular region.
B. Loss of skin elasticity is a normal aging process and not specifically indicative of dehydration. It can be seen in older adults regardless of hydration status.
C. Warm and dry skin can be a sign of dehydration. Dehydration leads to reduced sweating, which can result in dry skin, and it may also increase the body temperature, making the skin feel warm.
D. Thinning hair, especially in the lower extremities, is typically associated with circulatory issues or aging. It is not a direct sign of dehydration.

A. Increased risk for falling. B. Expected results for an older adult. C. Need for a walker to aid in ambulation. D. Likely onset of Parkinson's disease.

Correct Answer is A

Explanation

A. A Tinetti balance score of 12 and a gait score of 8 are indicative of an increased risk for falls. A total score below 19 suggests significant fall risk and a need for interventions to prevent injury.
B. While the results may reflect some age-related changes, they are lower than expected for a healthy older adult without significant mobility issues.
C. The results suggest an increased risk for falls but do not automatically indicate a need for a walker. Further assessment of functional capacity is needed.
D. The results do not specifically indicate Parkinson's disease, although balance and gait issues may be present in such conditions. Parkinson’s diagnosis would require additional motor and neurological assessments.

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The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing an older adult client, which finding is most indicative of dehydration?

Correct Answer is A

Explanation

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

Correct Answer is A

Explanation

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

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When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?