Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?

2+ pitting edema of the feet.

Pallor.

Orthopnea.

Right-sided paralysis.

Answer and Explanation

The Correct Answer is C

A.   2+ pitting edema of the feet. While edema requires monitoring and may necessitate some adjustments in care, it does not directly impact the ability to provide a bed bath.
B.   Pallor. Pallor indicates potential anemia or poor circulation but does not directly impact the provision of a bed bath.

C.   Orthopnea. Orthopnea, difficulty breathing when lying flat, is critical to consider when planning a bed bath. The client may need to be positioned with the head elevated to facilitate breathing and ensure comfort during the bath.
D.   Right-sided paralysis. Paralysis requires careful handling to prevent injury, but it is not as

immediately critical to the bathing process as orthopnea, which directly affects the client's ability to breathe comfortably.

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Correct Answer is B

Explanation

A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.

B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.

C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.

D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.

A. Neurological status B. Circulation C. Current medications D. Allergies E. Exposure F. Ventilation

Correct Answer is ["A","B","E"]

Explanation

A. Neurological status: Assessing the neurological status is crucial in the primary survey to

determine the client's level of consciousness, pupil reactions, and response to stimuli. This helps in identifying any potential brain injury or neurological deficits resulting from the fall.

B. Circulation: Evaluating circulation involves assessing the client's heart rate, blood pressure, and peripheral perfusion. In this scenario, the client's heart rate and blood pressure are provided in the nurse's notes, indicating the need to assess circulation as part of the primary survey.

C. Current medications: While important for the overall assessment and care of the client, assessing current medications is typically part of the secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions.

D. Allergies: While allergies are essential information for the client's overall care, they are typically addressed during the secondary survey or during the history-taking process rather than as part of the primary survey.

E. Exposure: Assessing exposure involves ensuring the client is adequately covered and protected from environmental factors, especially in trauma situations where there may be significant blood loss or risk of hypothermia. This includes removing clothing to assess for additional injuries or bleeding.

F. Ventilation: While ventilation is crucial for assessing the client's respiratory status, including respiratory rate and effort, it is typically part of the primary survey rather than the primary survey itself. Assessing ventilation helps determine if the client is adequately breathing and oxygenating.

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Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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