When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

Ask the client if he knows the year he married his wife.

Determine if the client can recall what he ate for breakfast.

Instruct the client to follow a three-step task.

Tell the client to repeat a series of unrelated numbers.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Asking the client if he knows the year he married his wife assesses long-term memory, not recent memory.
Choice B rationale
Determining if the client can recall what he ate for breakfast assesses recent memory but does not provide a comprehensive assessment.
Choice C rationale
Instructing the client to follow a three-step task assesses the client’s ability to process and remember recent information, providing a more thorough evaluation of recent memory.
Choice D rationale
Telling the client to repeat a series of unrelated numbers assesses short-term memory and attention, not specifically recent memory.

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Correct Answer is B

Explanation

A. Document the presence of borborygmi.Loud, high-pitched, and almost continuous gurgling sounds can indicate borborygmi.However, the nurse should not immediately document without fully assessing all four quadrants to ensure a comprehensive evaluation of bowel sounds.

B. Auscultate the remaining quadrants.A complete assessment of bowel sounds involves auscultating all four quadrants to determine if the sounds are generalized, localized, or absent in other areas. This provides a more accurate assessment of the client’s gastrointestinal function.

C. Elevate the head of the client’s bed immediately.The client’s position does not typically affect bowel sounds, and elevating the head of the bed is unnecessary unless the client has difficulty breathing or other non-gastrointestinal concerns.

D. Use the bell of the stethoscope to auscultate again.Using the bell, which is intended for low-pitched sounds like bruits or heart murmurs, would not provide any additional relevant information.

A. Ask the client to describe any other related symptoms. B. Place the dorsum of the hand on the client’s forehead. C. Use both hands to hold and palpate the client’s hands. D. Lightly pinch a fold of skin over the client’s sternum.

Correct Answer is B

Explanation

Choice A rationale
Asking the client to describe any other related symptoms is important for a comprehensive assessment but does not objectively confirm the presence of fever.
Choice B rationale
Placing the dorsum of the hand on the client’s forehead is a quick and practical method to assess for fever. It provides an initial subjective assessment of the client’s temperature before taking an accurate measurement with a thermometer.
Choice C rationale
Using both hands to hold and palpate the client’s hands may help assess for other symptoms such as clamminess or coldness but does not objectively confirm the presence of fever.
Choice D rationale
Lightly pinching a fold of skin over the client’s sternum assesses skin turgor and hydration status but does not objectively confirm the presence of fever.

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When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

Correct Answer is B

Explanation

To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?

Correct Answer is B

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

In assessing a client’s neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?