A client comes to the clinic with a report of fever and a recent
exposure to someone who was diagnosed with meningitis.
Which nursing assessment should be completed during the
initial examination of this client?
A) Level of consciousness.
B) Gait characteristics.
C) Presence of trauma.
D) Bladder control ability. Correct Answers A) Level of
consciousness
Initial symptoms of meningitis include headache, fatigue, stiff
neck, and changes in level of consciousness. It is necessary to
determine if the client is demonstrating signs of meningitis
before planning immediate care.
A client has just returned from the recovery room and asks to get
out of bed to go to the bathroom. The nurse decides to obtain
orthostatic vital signs first. How will the nurse position the client
to begin this procedure?
A) Lying.
B) Sitting.
C) Leaning.
D) Standing. Correct Answers A) Lying
When obtaining orthostatic vital signs, the nurse takes serial
measurements of pulse and blood pressure. The order of
positions for obtaining orthostaticvital signs is lying, sitting, and
then standing.
,A client is in the clinic and is reporting lower abdominal pain
and constipation. Which information is of greatest concern to the
nurse when obtaining the health history from this client?
A) Administration of rubeola vaccine at age 7.
B) Removal of gallbladder 5 years ago.
C) Family history of colon cancer on mother's side.
D) Family history of hypertension on father's side. Correct
Answers C) Family history of colon cancer on mother's side
Abdominal pain and constipation can be signs of colon cancer,
and some forms of colon cancer can be hereditary. A family
history of colon cancer is of significant concern, and the nurse
should report this information to the healthcare provider.
A client is in the clinic for a routine health examination. The
nurse notices the client appears underweight. Which question is
most important for the nurse to ask when completing the health
history of this client?
A) What types of food do you like or dislike?
B) Have you experienced sudden weight loss?
C) Do you use dietary supplements every day?
D) Can you recall the last 24 hours of food intake? Correct
Answers B) Have you experienced sudden weight loss?
A client who is underweight may have an underlying illness, for
example, weight loss without any change in dietary and/or
physical activity could be an indicator of the presence of cancer
or a metabolic syndrome such as Grave's disease. It is important
to determine if the weight loss has been sudden, gradual, and/or
intentional because this information will guide the remaining
dietary history.
, A client is reporting chest pain. What statement made by the
client, helps the nurse to understand this client has a naturalistic
belief in the cause of illness?
A) "My life is really out of balance."
B) "I knew I should have changed my diet."
C) "I should have gone to church last week."
D) "I forgot to take my medicines last night." Correct Answers
A) "My life is really out of balance."
The cause of disease may be viewed from three ways:
biomedical, naturalistic, magicoreligious. People who conform
to the naturalistic perspecive of disease causation, believe that
the forces of nature must be kept in a natural balance or
harmony.
A client reports feeling increasingly fatigued for several months,
and the nurse observes that the client's lips are pale. Which
additional data should the nurse collect based on this
presentation?
A) Current alcohol and tobacco use.
B) A 24-hour dietary recall.
C) Use of vitamin and iron supplements.
D) Daily pattern of oral hygiene practices. Correct Answers C)
Use of vitamin and iron supplements
Increasing fatigue and pale lips could indicate anemia. The nurse
should determine if the client is taking vitamin or iron
supplements to manage anemia.
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