NCLEX Nursing Assessment Practice Exam
A nurse is assessing a client who reports a headache. Which of the following questions should the nurse ask first?
Have you ever experienced headaches like this before?
B) How long have you been experiencing this headache?
C) Do you have a family history of headaches?
D) Have you been taking any medications for the pain?
The nurse is assessing a 45-year-old client for risk factors of cardiovascular disease. Which of the following is the most important question to ask?
Have you had any surgeries in the past?
B) Do you drink alcohol?
C) Do you have a family history of cardiovascular disease?
D) Are you experiencing shortness of breath?
During a routine physical examination, the nurse auscultates a heart murmur. What is the nurse’s next action?
Document the finding and report it to the healthcare provider.
B) Notify the family immediately.
C) Perform a neurological assessment.
D) Reassess the heart sounds after repositioning the client.
A client presents with complaints of chest pain. What should the nurse prioritize in the assessment?
Assessing vital signs
B) Asking about the duration and quality of the pain
C) Determining the client’s medical history
D) Checking for signs of anxiety or depression
The nurse is assessing a client with diabetes. Which of the following findings is most concerning?
Blood pressure of 130/85 mmHg
B) Blood glucose level of 160 mg/dL
C) Urine output of 50 mL per hour
D) Pedal pulses are faint but palpable
The nurse is assessing a client for risk factors associated with deep vein thrombosis (DVT). Which of the following should the nurse assess first?
Client’s level of activity
B) History of recent surgery or trauma
C) Family history of blood clotting disorders
D) Recent use of contraceptives
When performing a neurological assessment, the nurse notices that the client has difficulty following commands. What is the nurse’s first action?
Reassess the client’s motor function
B) Ask the client to perform simple tasks again
C) Check the client’s level of consciousness and orientation
D) Immediately notify the healthcare provider
The nurse is assessing a client with a history of asthma. Which of the following findings would require immediate intervention?
Respiratory rate of 18 breaths per minute
B) Oxygen saturation of 92% on room air
C) Use of accessory muscles during breathing
D) Wheezing heard only on expiration
A nurse is performing an abdominal assessment. Which of the following is the correct sequence for this assessment?
Inspection, percussion, palpation, auscultation
B) Inspection, auscultation, percussion, palpation
C) Palpation, auscultation, percussion, inspection
D) Percussion, palpation, inspection, auscultation
A client reports sudden, severe pain in the lower back. Which of the following actions should the nurse take first?
Assess the client’s vital signs
B) Palpate the affected area for tenderness
C) Ask the client to rate the pain on a scale of 0 to 10
D) Assist the client to a comfortable position
The nurse is assessing a client with a suspected urinary tract infection (UTI). Which symptom would be most indicative of this condition?
Dysuria and fever
B) Nausea and vomiting
C) Diarrhea and bloating
D) Weight loss and fatigue
During a health assessment, the nurse asks the client about their sleep patterns. The client reports difficulty staying asleep. Which of the following questions should the nurse ask next?
Have you been drinking caffeine before bedtime?
B) Do you wake up feeling refreshed?
C) How long have you had difficulty sleeping?
D) Do you snore or have breathing problems while sleeping?
The nurse is assessing a client’s skin turgor. Which of the following findings would indicate dehydration?
Tenting of the skin
B) Pink and warm skin
C) Full, elastic skin
D) Rapid capillary refill
The nurse is assessing a client for signs of dehydration. Which of the following findings would be most concerning?
Decreased skin turgor
B) Increased heart rate
C) Dry mucous membranes
D) Low-grade fever
The nurse is performing a cardiac assessment on a client. Which of the following findings should be reported to the healthcare provider immediately?
Heart rate of 80 bpm
B) S1 and S2 heart sounds
C) Heart murmur grade II/VI
D) Irregular rhythm with occasional skipped beats
The nurse is assessing a client’s respiratory status. Which of the following findings indicates a need for further evaluation?
Respiratory rate of 20 breaths per minute
B) Bilateral lung expansion on palpation
C) Adventitious breath sounds in both lungs
D) Oxygen saturation of 95% on room air
The nurse is assessing a client with a history of hypertension. Which of the following would be the most appropriate action?
Measure blood pressure in both arms
B) Ask the client about recent weight loss
C) Assess for signs of peripheral edema
D) Check the client’s pulse rate
The nurse is performing a musculoskeletal assessment. Which of the following should the nurse ask the client first?
Do you experience any pain or stiffness in your joints?
B) Do you have a family history of arthritis?
C) When did you last exercise?
D) Have you had any fractures or injuries in the past?
The nurse is assessing a 70-year-old client for risk factors for falls. Which of the following factors should be assessed first?
Cognitive function
B) Medications
C) History of previous falls
D) Home safety environment
The nurse is performing a mental health assessment on a client. Which of the following findings would require immediate action?
Client reports feeling sad but denies suicidal thoughts
B) Client expresses a desire to harm others
C) Client is tearful but engaged in conversation
D) Client reports difficulty concentrating at work
The nurse is assessing a client with an open fracture. Which of the following is the priority action?
Apply a sterile dressing to the wound
B) Assess the client’s pain level
C) Perform a neurovascular assessment of the affected limb
D) Immobilize the fractured area
The nurse is assessing a client with suspected hypoglycemia. Which of the following symptoms would be most indicative of this condition?
Shaking, sweating, and confusion
B) Increased thirst, urination, and fatigue
C) Blurred vision and headache
D) Nausea, vomiting, and abdominal pain
During a health assessment, the nurse finds that the client has a fever. Which of the following is the most important next step?
Obtain a complete blood count (CBC)
B) Assess the client’s temperature every hour
C) Determine the cause of the fever
D) Administer an antipyretic medication
The nurse is assessing a client who is obese. Which of the following is the most important question to ask regarding their weight management?
Have you been on any weight-loss programs?
B) Do you follow a specific diet plan?
C) Have you experienced any significant changes in appetite?
D) Do you exercise regularly?
A client has a history of chronic obstructive pulmonary disease (COPD). What should the nurse assess first?
Respiratory rate and lung sounds
B) Client’s ability to perform activities of daily living
C) Oxygen saturation and pulse rate
D) Capillary refill time and skin color
The nurse is assessing a client with a potential stroke. Which of the following findings is most suggestive of this condition?
Sudden, severe headache and nausea
B) Difficulty speaking and weakness on one side of the body
C) Fever and chills
D) Pain in the chest and shortness of breath
The nurse is conducting a head-to-toe assessment. Which of the following is the most appropriate action when assessing the client’s head and neck?
Palpate the skull for any abnormalities
B) Ask the client to turn their head to the left and right
C) Check the neck veins for distention
D) Inspect the mouth for sores or lesions
The nurse is performing a skin assessment. Which of the following findings should be documented as a potential skin cancer risk?
Symmetrical mole with uniform color
B) Asymmetrical mole with uneven borders
C) Mole with a smooth, even border
D) Mole with a smaller diameter than a pencil eraser
The nurse is assessing a client with a history of gastrointestinal reflux disease (GERD). Which of the following questions should the nurse ask first?
Have you been experiencing any heartburn?
B) Do you have difficulty swallowing?
C) Have you lost weight recently?
D) Do you have a history of ulcers?
The nurse is assessing a client for signs of anemia. Which of the following symptoms would be most indicative of this condition?
Pallor and fatigue
B) Elevated blood pressure and headache
C) Weight gain and dizziness
D) Abdominal pain and nausea
The nurse is assessing a client with suspected pneumonia. Which of the following findings would be most concerning?
Clear breath sounds in the lower lobes
B) Temperature of 101.5°F (38.5°C)
C) Cyanosis of the lips and nail beds
D) Productive cough with yellow sputum
The nurse is assessing a client who recently had abdominal surgery. Which of the following findings should the nurse report to the healthcare provider?
Client has slight abdominal distention
B) Client has passed flatus and has a bowel movement
C) Client is experiencing moderate pain at the incision site
D) Client has absent bowel sounds in all quadrants
The nurse is assessing a client who is on a low-sodium diet for hypertension. Which food should the nurse recommend?
Bacon
B) Canned soup
C) Fresh vegetables
D) Processed cheese
The nurse is assessing a client who reports feeling lightheaded when standing up. What should the nurse assess first?
Blood pressure and heart rate
B) Oxygen saturation
C) Respiratory rate and depth
D) Skin temperature and color
The nurse is assessing a client with a history of renal failure. Which laboratory finding should be most concerning?
Serum creatinine level of 3.5 mg/dL
B) Hemoglobin level of 12 g/dL
C) Blood urea nitrogen (BUN) level of 15 mg/dL
D) Potassium level of 4.0 mEq/L
The nurse is assessing a postpartum client. Which finding would require immediate action?
Firm and contracted uterus
B) Lochia rubra with a moderate amount of flow
C) Severe abdominal cramping and fever
D) Dizziness and weakness after standing up
The nurse is assessing a client with asthma. Which of the following findings would indicate the need for emergency intervention?
Wheezing with coughing
B) Shortness of breath with mild exertion
C) Oxygen saturation of 92% on room air
D) Severe difficulty breathing and use of accessory muscles
The nurse is assessing a client’s nutritional status. Which of the following is most indicative of protein deficiency?
Dry, flaky skin
B) Shortness of breath
C) Weight gain and edema
D) Balding and excessive hair loss
The nurse is performing a neurological assessment on a client. Which of the following is the most appropriate first step?
Test the client’s pupillary response to light
B) Assess the client’s level of consciousness
C) Evaluate the client’s muscle strength
D) Ask the client to move their extremities
The nurse is assessing a client with a history of migraines. Which of the following should be included in the assessment?
Family history of neurological disorders
B) Recent use of over-the-counter analgesics
C) Onset, duration, and triggers of the headache
D) History of hypertension or diabetes
The nurse is assessing a client with chronic pain. Which of the following is the most appropriate question to ask?
“How would you rate your pain on a scale of 0 to 10?”
B) “When did you first start feeling pain?”
C) “Do you think the pain is related to any specific event?”
D) “Do you want pain medication now or later?”
The nurse is assessing a client who is at risk for skin breakdown. Which of the following findings is most concerning?
Pressure ulcers on the sacrum and heels
B) Dry and flaky skin on the elbows
C) Mild redness in the area of the hip bones
D) Skin warm to the touch with no visible lesions
The nurse is assessing a client with congestive heart failure. Which of the following findings requires immediate action?
Dyspnea on exertion
B) Bilateral crackles heard in the lungs
C) Weight gain of 2 pounds in 24 hours
D) Peripheral edema of the ankles
The nurse is assessing a client’s respiratory function. Which of the following findings is most suggestive of early hypoxia?
Cyanosis of the lips and extremities
B) Decreased blood pressure and heart rate
C) Restlessness and anxiety
D) Abdominal pain and vomiting
The nurse is assessing a client who has a fever. What is the most important assessment to determine the severity of the infection?
Assess the client’s blood pressure
B) Determine the client’s temperature trend
C) Check the client’s pulse rate
D) Measure the client’s oxygen saturation
The nurse is assessing a client who is 24 hours post-op after a hip replacement. Which finding requires immediate action?
Redness and mild swelling at the surgical site
B) Pain at the surgical site with movement
C) Temperature of 100.4°F (38°C)
D) Sudden sharp chest pain and shortness of breath
The nurse is performing a head-to-toe assessment on a client. Which of the following is the most appropriate first step when assessing the respiratory system?
Palpate the chest for tenderness
B) Ask the client to cough deeply
C) Auscultate lung sounds from the front and back
D) Measure the client’s oxygen saturation
The nurse is performing a cardiovascular assessment. Which of the following findings is most concerning?
Heart rate of 72 bpm
B) Dullness on percussion of the abdomen
C) S1 and S2 heart sounds audible without murmurs
D) Jugular vein distention
The nurse is assessing a client with chronic kidney disease. Which of the following laboratory values is the most important to monitor?
Blood urea nitrogen (BUN)
B) White blood cell (WBC) count
C) Hemoglobin level
D) Serum sodium level
The nurse is assessing a client who is receiving chemotherapy. Which finding would be most concerning?
Mild fatigue and decreased appetite
B) Mild nausea and vomiting
C) Temperature of 100.5°F (38°C) and chills
D) Sore throat and hoarseness
The nurse is assessing a client with diabetic neuropathy. Which of the following findings would be most indicative of nerve damage?
Tingling and numbness in the extremities
B) Elevated blood glucose levels
C) Increased thirst and frequent urination
D) Skin redness and swelling
The nurse is assessing a client’s hearing. Which of the following findings is most suggestive of conductive hearing loss?
Client reports muffled hearing and fullness in the ear
B) Client reports ringing in the ears (tinnitus)
C) Client’s speech is slurred and difficult to understand
D) Client has difficulty hearing low-frequency sounds
The nurse is assessing a client’s blood pressure. Which of the following findings would be most indicative of hypertension?
Blood pressure reading of 118/76 mmHg
B) Blood pressure reading of 130/88 mmHg
C) Blood pressure reading of 140/90 mmHg
D) Blood pressure reading of 110/70 mmHg
The nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings is most concerning?
Oxygen saturation of 89% on room air
B) Decreased lung sounds on auscultation
C) Chronic cough and expectoration of sputum
D) Elevated respiratory rate of 22 breaths per minute
The nurse is performing a musculoskeletal assessment on a client with arthritis. Which of the following findings is most indicative of inflammation?
Tenderness and swelling of the affected joint
B) Warmth and redness at the joint site
C) Decreased range of motion
D) Aching pain that increases with movement
The nurse is assessing a client with hypothyroidism. Which of the following symptoms is most likely to be reported?
Excessive sweating and heat intolerance
B) Weight loss despite increased appetite
C) Fatigue, weight gain, and cold intolerance
D) Increased heart rate and palpitations
The nurse is assessing a client for signs of dehydration. Which of the following is the most significant indicator?
Decreased skin turgor
B) Increased urine output
C) Moist mucous membranes
D) Normal heart rate and blood pressure
The nurse is performing an assessment on a client with anxiety. Which of the following would be the most appropriate initial action?
Discuss the client’s family history of anxiety
B) Teach the client relaxation techniques
C) Administer an anti-anxiety medication
D) Assess the client’s current level of anxiety
The nurse is assessing a client with chronic fatigue syndrome. Which of the following findings would be most indicative of this condition?
Sudden, unexplained weight loss
B) Persistent, unexplained fatigue lasting more than six months
C) Pain in the joints with no swelling or redness
D) Shortness of breath with exertion
The nurse is assessing a client’s mental status. Which of the following is the most appropriate question to assess cognitive function?
“Can you tell me the current date and time?”
B) “How are you feeling today?”
C) “What medications are you currently taking?”
D) “Do you have any concerns about your health?”
The nurse is assessing a client who is postoperative after a knee replacement. Which of the following is the priority assessment?
Pain level at the surgical site
B) Redness and warmth at the incision site
C) Deep vein thrombosis (DVT) assessment
D) Intake and output
The nurse is performing an abdominal assessment. Which of the following is the correct order of techniques?
Inspection, palpation, percussion, auscultation
B) Palpation, inspection, percussion, auscultation
C) Inspection, auscultation, percussion, palpation
D) Auscultation, inspection, percussion, palpation
The nurse is assessing a client with hypertension. Which of the following findings is most likely to indicate uncontrolled hypertension?
Blood pressure of 130/85 mmHg
B) Blood pressure of 145/95 mmHg
C) Blood pressure of 120/80 mmHg
D) Blood pressure of 160/110 mmHg
The nurse is assessing a client with liver disease. Which of the following is the most concerning finding?
Increased bruising and petechiae
B) Jaundice of the sclera
C) Ascites and peripheral edema
D) Fatigue and weakness
The nurse is assessing a client’s fluid balance. Which of the following findings would most likely indicate hypovolemia?
Edema in the lower extremities
B) Dry mucous membranes and poor skin turgor
C) Increased blood pressure and weight gain
D) Bilateral crackles in the lungs
The nurse is assessing a client with a history of diabetes. Which of the following symptoms would most likely be associated with diabetic ketoacidosis (DKA)?
Polyuria, polydipsia, and rapid breathing
B) Sweating, tremors, and confusion
C) Fatigue, weight gain, and elevated blood pressure
D) Shallow respirations, increased thirst, and slow capillary refill
The nurse is performing a pain assessment on a postoperative client. Which of the following questions would be most appropriate to assess the client’s pain?
“How much pain do you have on a scale of 0 to 10?”
B) “When did the pain start?”
C) “Have you taken any pain medication today?”
D) “Do you want me to help you with your pain now?”
The nurse is assessing a client who has been on long-term corticosteroid therapy. Which of the following findings would be most concerning?
Weight gain and increased appetite
B) Dizziness and headache
C) Increased blood sugar and delayed wound healing
D) Mild edema and joint stiffness
The nurse is assessing a client with a recent myocardial infarction. Which finding requires immediate intervention?
Oxygen saturation of 94%
B) Heart rate of 88 bpm
C) Sudden shortness of breath and chest pain
D) Mild swelling in the lower extremities
The nurse is assessing a client who has a history of stroke. Which of the following findings is most concerning?
Decreased sensation on one side of the body
B) Difficulty swallowing and choking on food
C) Slurred speech and weakness in the arms
D) Inability to walk without assistance
The nurse is assessing a client with a respiratory infection. Which of the following findings is most suggestive of a severe infection?
Productive cough with clear sputum
B) Oxygen saturation of 92% on room air
C) Fever of 101.5°F (38.5°C) and tachypnea
D) Mild sore throat and fatigue
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings is most likely to be present?
Shortness of breath with minimal exertion
B) Increased respiratory rate with hypoventilation
C) Cyanosis of the lips and extremities
D) Elevated blood pressure and bradycardia
The nurse is assessing a client with a possible fracture. Which of the following findings should the nurse prioritize?
Bruising and swelling at the injury site
B) Deformity and inability to bear weight
C) Pain at the injury site with movement
D) Limited range of motion at the affected joint
The nurse is assessing a client who is on a mechanical ventilator. Which of the following findings should be reported immediately?
Oxygen saturation of 92%
B) Respiratory rate of 18 breaths per minute
C) Sudden decrease in blood pressure
D) Presence of bilateral crackles on auscultation
The nurse is assessing a client’s neurological status. Which of the following is the most appropriate action when assessing the client’s pupils?
Measure pupil size with a penlight
B) Observe for redness or drainage in the eyes
C) Test the client’s ability to follow commands with the eyes
D) Check for bilateral pupil reaction to light
The nurse is assessing a client with pneumonia. Which of the following findings is most likely to be present?
Rapid, shallow breathing with a productive cough
B) Decreased oxygen saturation and cyanosis
C) Sore throat and swollen lymph nodes
D) Decreased breath sounds and dull percussion over the lungs
The nurse is assessing a client with an abnormal heart rhythm. Which of the following findings would be most concerning?
Heart rate of 60 bpm with normal sinus rhythm
B) Premature ventricular contractions (PVCs) with regular rhythm
C) Irregularly irregular rhythm with no palpable pulse
D) Pulse rate of 80 bpm with a slight arrhythmia
The nurse is assessing a client with dehydration. Which of the following is the most appropriate action?
Encourage the client to drink large amounts of fluids
B) Administer IV fluids as ordered
C) Apply cool compresses to the skin
D) Restrict fluid intake to avoid overload
The nurse is assessing a client with a history of alcohol abuse. Which of the following findings is most indicative of withdrawal?
Tremors, irritability, and elevated heart rate
B) Increased appetite and drowsiness
C) Bradycardia and hypotension
D) Nausea, vomiting, and confusion
The nurse is assessing a client with a suspected thyroid disorder. Which of the following is most likely to be assessed?
Weight gain, cold intolerance, and fatigue
B) Weight loss, heat intolerance, and nervousness
C) Increased blood pressure and bradycardia
D) Dry skin, constipation, and hair loss
The nurse is performing a head-to-toe assessment on a client. Which of the following findings requires immediate action?
Fever of 101°F (38.3°C)
B) Hypertension with a blood pressure of 180/110 mmHg
C) Clear lung sounds on auscultation
D) Slight redness at the surgical site
The nurse is assessing a client with anxiety. Which of the following findings is most likely to be present?
Decreased heart rate and shallow respirations
B) Increased blood pressure and heart rate
C) Decreased blood pressure and cold extremities
D) Increased respiratory rate and cyanosis
The nurse is assessing a client with a history of depression. Which of the following findings is most likely to be present?
Increased energy and elation
B) Decreased appetite and weight loss
C) Increased need for sleep and excessive energy
D) Manic episodes and racing thoughts
The nurse is assessing a client with heart failure. Which of the following is most likely to be found?
Peripheral edema, jugular vein distention, and crackles
B) Bradycardia, hypotension, and dry cough
C) Tachypnea, orthostatic hypotension, and cool extremities
D) Elevated temperature, increased pulse, and decreased respiratory rate
The nurse is assessing a client with diabetes mellitus. Which of the following is the most important factor to monitor?
Blood glucose levels
B) Skin temperature and color
C) Blood pressure
D) Respiratory rate and depth
The nurse is assessing a client with a history of stroke. Which of the following would be most indicative of a complication?
Facial drooping on one side
B) Decreased sensation in the arms and legs
C) Difficulty swallowing and aspiration risk
D) Numbness in the lower extremities
The nurse is assessing a client who has been on bed rest for an extended period. Which of the following is the most important to monitor?
Skin integrity and signs of pressure ulcers
B) Respiratory rate and oxygen saturation
C) Digestive function and bowel sounds
D) Serum electrolyte levels
The nurse is assessing a client with a history of asthma. Which of the following findings requires immediate intervention?
Mild wheezing on expiration
B) Shortness of breath and use of accessory muscles
C) Increased sputum production with coughing
D) Oxygen saturation of 94% on room air
The nurse is assessing a client who has just received a blood transfusion. Which of the following findings requires immediate action?
Fever of 100.2°F (37.9°C)
B) Mild rash on the upper torso
C) Shortness of breath and chest tightness
D) Increase in heart rate from 70 bpm to 85 bpm
The nurse is assessing a client with a head injury. Which of the following findings is most concerning?
Decreased level of consciousness and confusion
B) Mild headache and dizziness
C) Nausea and vomiting
D) Complaints of blurred vision
The nurse is assessing a client with a suspected myocardial infarction. Which of the following is the most common symptom associated with this condition?
Severe chest pain radiating to the left arm
B) Sudden onset of shortness of breath
C) Severe headache and blurred vision
D) Abdominal pain and nausea
The nurse is assessing a client with chronic kidney disease. Which of the following findings is most likely to be observed?
Decreased blood pressure and increased heart rate
B) Edema, weight gain, and increased blood pressure
C) Increased blood glucose levels and fatigue
D) Rapid, shallow breathing and cyanosis
The nurse is assessing a client with a suspected stroke. Which of the following symptoms is most concerning?
Slurred speech and right-sided weakness
B) Sudden loss of vision in one eye
C) Complaints of dizziness and nausea
D) Decreased appetite and fatigue
The nurse is assessing a client with a history of asthma. Which of the following findings is most likely to indicate an asthma exacerbation?
Wheezing, coughing, and shortness of breath
B) Clear sputum and absence of wheezing
C) Increased energy and activity tolerance
D) Increased appetite and weight gain
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings is most likely?
Tachypnea, wheezing, and barrel chest
B) Cyanosis, productive cough, and fever
C) Increased oxygen saturation and clear lung sounds
D) Elevated blood pressure and pulse
The nurse is assessing a client with acute pancreatitis. Which of the following is most likely to be present?
Severe abdominal pain, nausea, and vomiting
B) Abdominal distension with mild discomfort
C) Increased energy and appetite
D) Diarrhea and low-grade fever
The nurse is assessing a client with a history of tuberculosis. Which of the following findings is most concerning?
Persistent cough with hemoptysis
B) Mild chest pain and low-grade fever
C) Swollen lymph nodes and night sweats
D) Weight loss and fatigue
The nurse is assessing a client with a history of cirrhosis. Which of the following findings would most likely be present?
Jaundice, ascites, and edema
B) Increased appetite and weight gain
C) Nausea and vomiting with abdominal pain
D) Hypotension and tachycardia
The nurse is assessing a client with a history of seizures. Which of the following is most concerning?
History of nocturnal seizures only
B) Sudden onset of confusion and agitation
C) Lack of auras before seizure activity
D) New onset of headaches and visual disturbances
The nurse is assessing a client who has a wound infection. Which of the following findings is most concerning?
Redness, warmth, and swelling at the wound site
B) Slight drainage from the wound and mild pain
C) Pain with movement and minimal swelling
D) Sudden increase in drainage and fever
The nurse is assessing a client with fluid overload. Which of the following findings is most likely?
Shortness of breath, crackles in the lungs, and edema
B) Dehydration, hypotension, and dizziness
C) Increased urine output and low blood pressure
D) Dry skin, confusion, and rapid pulse
The nurse is assessing a client with diabetes mellitus. Which of the following findings would most likely indicate hyperglycemia?
Tremors, confusion, and sweating
B) Rapid breathing, fruity-smelling breath, and nausea
C) Fatigue, dizziness, and cold skin
D) Increased appetite and blurred vision
The nurse is assessing a client with an allergic reaction. Which of the following findings is most concerning?
Mild rash and itching on the arms
B) Wheezing and shortness of breath
C) Swelling around the eyes and lips
D) Low-grade fever and sore throat
The nurse is assessing a client who is receiving chemotherapy. Which of the following findings is most likely to be related to the treatment?
Weight gain and hypertension
B) Nausea, vomiting, and hair loss
C) Increased energy and activity tolerance
D) Decreased white blood cell count and bruising
The nurse is assessing a client with a history of hypertension. Which of the following findings is most concerning?
Blood pressure reading of 160/95 mmHg
B) Blood pressure reading of 130/85 mmHg
C) Blood pressure reading of 120/80 mmHg
D) Blood pressure reading of 140/90 mmHg
The nurse is assessing a client who has recently had a stroke. Which of the following is the most important aspect to assess first?
Level of consciousness and orientation
B) Muscle strength and coordination
C) Blood pressure and heart rate
D) Speech patterns and facial symmetry
The nurse is assessing a client who is 24 hours postoperative after a hip replacement surgery. Which of the following should the nurse monitor most closely?
Pain level and incision site for signs of infection
B) Vital signs and mental status for signs of delirium
C) Range of motion and strength in the affected leg
D) Urinary output and hydration status
The nurse is assessing a client with a suspected deep vein thrombosis (DVT). Which of the following signs and symptoms would be most concerning?
Swelling and tenderness in the calf with redness
B) Complaints of leg cramping and mild swelling
C) No swelling or pain in the affected leg
D) Localized bruising and redness at the site
The nurse is assessing a client with asthma. Which of the following findings is most indicative of a severe asthma attack?
Severe wheezing and inability to speak in full sentences
B) Mild shortness of breath with normal oxygen saturation
C) Absence of wheezing with clear breath sounds
D) Persistent cough with clear sputum production
The nurse is assessing a client with a history of anxiety. Which of the following symptoms is most commonly associated with an anxiety attack?
Increased heart rate, shortness of breath, and chest tightness
B) Decreased appetite, dizziness, and lightheadedness
C) Shaking, nausea, and excessive thirst
D) Muscle weakness, confusion, and cold extremities
The nurse is assessing a client with a history of rheumatoid arthritis. Which of the following is the most concerning finding?
Joint stiffness in the morning
B) Decreased range of motion in affected joints
C) Swelling, warmth, and redness at the joint sites
D) Fatigue and mild weight loss
The nurse is assessing a client with a suspected gastrointestinal bleed. Which of the following findings would be most concerning?
Melena and low blood pressure
B) Abdominal tenderness and bloating
C) Decreased appetite and mild fatigue
D) Pale skin and constipation
The nurse is assessing a client with a wound infection. Which of the following findings would indicate the need for immediate action?
Purulent drainage and increased pain
B) Mild redness and swelling at the site
C) Slight warmth and tenderness around the wound
D) Clear drainage and no fever
The nurse is assessing a client with a history of heart failure. Which of the following findings should be immediately reported to the healthcare provider?
Shortness of breath with exertion
B) Increased weight gain and ankle edema
C) Sudden onset of chest pain and palpitations
D) Fatigue and dizziness with mild exertion
The nurse is assessing a client who is on warfarin therapy. Which of the following is most concerning?
Slight bruising on the arms
B) Complaints of mild stomach upset
C) Presence of black, tarry stools
D) Occasional headache and dizziness
The nurse is assessing a client with a possible drug overdose. Which of the following findings is most concerning?
Decreased respiratory rate and pupil constriction
B) Increased heart rate and elevated blood pressure
C) Nausea and vomiting with confusion
D) Shallow respirations and cyanosis
The nurse is assessing a client with liver failure. Which of the following findings would be most indicative of worsening condition?
Decreased blood pressure and tachycardia
B) Jaundice, ascites, and confusion
C) Increased appetite and weight gain
D) Pale skin, dizziness, and fatigue
The nurse is assessing a client with diabetes mellitus. Which of the following findings would be indicative of diabetic neuropathy?
Decreased sensation in the extremities
B) Elevated blood glucose and hyperventilation
C) Tremors and increased heart rate
D) Dry mouth and increased thirst
The nurse is assessing a client with a history of stroke. Which of the following is the most concerning?
Inability to move the left arm
B) Mild headache and dizziness
C) Difficulty with speech and comprehension
D) Numbness in the right leg
The nurse is assessing a client who has just been admitted for possible appendicitis. Which of the following findings would be most concerning?
Low-grade fever and mild right lower quadrant pain
B) Nausea, vomiting, and severe right lower quadrant pain
C) Elevated white blood cell count and anorexia
D) Abdominal bloating and constipation
The nurse is assessing a client who has just been diagnosed with pneumonia. Which of the following findings is most indicative of pneumonia?
Shallow respirations and a productive cough with purulent sputum
B) Rapid pulse and increased blood pressure
C) Absence of cough with clear sputum
D) Painless breathing and no sputum production
The nurse is assessing a client with a history of chronic hypertension. Which of the following findings is most concerning?
Blood pressure of 140/88 mmHg
B) Blood pressure of 170/98 mmHg
C) Blood pressure of 120/78 mmHg
D) Blood pressure of 130/85 mmHg
The nurse is assessing a client who has recently undergone surgery for a hip replacement. Which of the following findings is most concerning?
Mild redness and swelling at the incision site
B) Slight pain at the surgical site and low-grade fever
C) Discomfort with movement and decreased range of motion
D) Sudden increase in pain, redness, and warmth at the surgical site
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?
Increase in shortness of breath and wheezing
B) Decreased appetite and weight loss
C) Use of accessory muscles to breathe and cyanosis
D) Productive cough with clear sputum
The nurse is assessing a client with a history of deep vein thrombosis (DVT). Which of the following findings would most likely indicate a complication?
Swelling in the affected leg and tenderness
B) Increased pain and redness at the site of the clot
C) Sudden shortness of breath and chest pain
D) Mild warmth and slight swelling at the affected site
The nurse is assessing a client with acute cholecystitis. Which of the following findings is most likely?
Pain in the right upper quadrant and nausea
B) Severe abdominal bloating and constipation
C) Pain in the left lower quadrant and diarrhea
D) Elevated temperature and abdominal tenderness
The nurse is assessing a client with a possible stroke. Which of the following findings is most concerning?
Facial drooping and inability to speak clearly
B) Sudden headache and dizziness
C) Weakness in the arms and legs
D) Numbness in the face and chest pain
The nurse is assessing a client with a suspected spinal cord injury. Which of the following findings would be most concerning?
Loss of sensation below the injury level
B) Difficulty moving the extremities
C) Inability to feel pain in the extremities
D) Incontinence of urine and stool
The nurse is assessing a client with a history of congestive heart failure. Which of the following findings would be most concerning?
Weight gain, shortness of breath, and edema
B) Mild fatigue and shortness of breath with exertion
C) No swelling or weight gain and normal breath sounds
D) Slight cough and no chest pain
The nurse is assessing a client who is receiving chemotherapy. Which of the following findings is most concerning?
Mild nausea and loss of appetite
B) Fatigue and hair loss
C) Sore mouth and bleeding gums
D) Fever and signs of infection
The nurse is assessing a client with a suspected myocardial infarction (MI). Which of the following findings is most characteristic of an MI?
Dizziness and a feeling of impending doom
B) Pain radiating to the left shoulder and arm
C) Shortness of breath and swelling in the legs
D) Increased appetite and weight gain
The nurse is assessing a client with a history of hypothyroidism. Which of the following findings would be most concerning?
Weight gain, cold intolerance, and constipation
B) Excessive thirst, frequent urination, and weight loss
C) Increased appetite, irritability, and weight gain
D) Rapid heartbeat and difficulty sleeping
The nurse is assessing a client with diabetes mellitus. Which of the following findings is most indicative of diabetic ketoacidosis (DKA)?
Rapid breathing, fruity-smelling breath, and nausea
B) Excessive thirst, weight gain, and fatigue
C) Slow heart rate, dry skin, and dizziness
D) Swelling in the legs and increased blood pressure
The nurse is assessing a client with acute renal failure. Which of the following findings would be most concerning?
Decreased urine output and elevated creatinine levels
B) Increased appetite and weight loss
C) Mild edema and low blood pressure
D) Frequent urination and normal kidney function tests
The nurse is assessing a client with a possible pulmonary embolism. Which of the following findings is most indicative of this condition?
Sudden onset of sharp chest pain and shortness of breath
B) Mild cough and low-grade fever
C) Pain in the lower abdomen and leg swelling
D) Persistent headache and dizziness
The nurse is assessing a client with a history of liver cirrhosis. Which of the following findings is most indicative of hepatic encephalopathy?
Confusion, altered level of consciousness, and tremors
B) Weight loss, increased appetite, and fatigue
C) Jaundice, elevated liver enzymes, and ascites
D) Elevated temperature and abdominal distention
The nurse is assessing a client who has recently undergone a total knee replacement. Which of the following findings is most concerning?
Slight swelling at the incision site
B) Decreased range of motion and discomfort in the affected leg
C) Sudden onset of shortness of breath and chest pain
D) Mild redness around the incision with no fever
The nurse is assessing a client with a history of asthma. Which of the following findings would indicate an asthma exacerbation?
Coughing, wheezing, and shortness of breath
B) Clear sputum production and normal oxygen saturation
C) Chest tightness and increased appetite
D) Mild cough and low-grade fever
The nurse is assessing a client with a possible gastrointestinal bleed. Which of the following findings is most concerning?
Black, tarry stools and low blood pressure
B) Abdominal bloating and constipation
C) Decreased appetite and mild fatigue
D) Pale skin and slight dizziness
The nurse is assessing a client with a history of peptic ulcer disease. Which of the following findings is most concerning?
Severe epigastric pain and vomiting blood
B) Mild heartburn and indigestion
C) Mild nausea and bloating after meals
D) Occasional burping and loss of appetite
The nurse is assessing a client with a possible seizure disorder. Which of the following findings would be most concerning?
Unexplained loss of consciousness and muscle twitching
B) Complaints of dizziness and nausea
C) Mild headache and visual disturbances
D) Decreased appetite and fatigue
The nurse is assessing a client with chronic pain due to osteoarthritis. Which of the following findings is most likely to be observed?
Joint stiffness, especially in the morning, and pain with movement
B) Swelling, redness, and warmth in the affected joints
C) Severe pain with rest and minimal movement
D) Decreased pain during activity and increased energy
The nurse is assessing a client with a history of sleep apnea. Which of the following findings would be most concerning?
Excessive daytime sleepiness and snoring at night
B) Difficulty concentrating and frequent headaches
C) Shortness of breath and difficulty breathing while sleeping
D) Insomnia and inability to stay asleep
The nurse is assessing a client with a history of anemia. Which of the following findings would indicate the need for further evaluation?
Fatigue, pallor, and shortness of breath
B) Mild dizziness and headache
C) Increased appetite and weight loss
D) Swelling in the legs and fatigue
The nurse is assessing a client with a history of diverticulitis. Which of the following findings would be most concerning?
Abdominal tenderness, fever, and nausea
B) Mild bloating and constipation
C) Increased appetite and weight gain
D) Abdominal cramps and diarrhea
The nurse is assessing a client who has recently been diagnosed with a urinary tract infection (UTI). Which of the following symptoms is most likely?
Frequent urination, dysuria, and cloudy urine
B) Increased appetite and mild fatigue
C) Chest pain and shortness of breath
D) Severe headache and blurred vision
The nurse is assessing a client with a history of migraines. Which of the following findings would be most concerning during a migraine attack?
Nausea, photophobia, and visual disturbances
B) Mild dizziness and difficulty concentrating
C) Decreased appetite and lightheadedness
D) Pain at the back of the neck and shoulders
The nurse is assessing a client with a history of stroke. Which of the following findings would be most concerning?
Sudden inability to speak and right-sided weakness
B) Mild headache and dizziness
C) Loss of appetite and fatigue
D) Numbness in the left arm and leg
The nurse is assessing a client with a suspected drug overdose. Which of the following findings would be most concerning?
Decreased respiratory rate and pinpoint pupils
B) Increased blood pressure and restlessness
C) Nausea and vomiting with dizziness
D) Shallow respirations and cyanosis
The nurse is assessing a client with a history of asthma. Which of the following findings is most likely to indicate an asthma attack?
Wheezing, coughing, and shortness of breath
B) Clear sputum production and normal oxygen saturation
C) Chest tightness and increased appetite
D) Mild cough and low-grade fever
The nurse is assessing a client with a history of heart failure. Which of the following findings is most indicative of worsening heart failure?
Decreased urine output and swelling in the legs
B) Mild shortness of breath and fatigue
C) Mild headache and dizziness
D) Increased appetite and weight loss
The nurse is assessing a client who is recovering from a stroke. Which of the following findings would indicate the need for further evaluation?
Right-sided weakness and inability to speak clearly
B) Slight confusion and slurred speech
C) Mild headache and dizziness
D) Difficulty moving the left leg and arm
The nurse is assessing a client with a history of peptic ulcer disease. Which of the following findings is most concerning?
Pain after eating and heartburn
B) Nausea, vomiting, and dark, tarry stools
C) Abdominal bloating and indigestion
D) Increased appetite and weight loss
The nurse is assessing a client who is receiving anticoagulant therapy. Which of the following findings would indicate a need for further evaluation?
Increased bruising and nosebleeds
B) Mild headache and dizziness
C) Pain in the lower back and legs
D) Abdominal pain and slight fatigue
The nurse is assessing a client with a history of chronic kidney disease. Which of the following findings would be most concerning?
Decreased urine output and fatigue
B) Increased thirst and frequent urination
C) Weight loss and high blood pressure
D) Edema and shortness of breath
The nurse is assessing a client with a history of asthma. Which of the following findings would indicate an asthma exacerbation?
Wheezing, coughing, and increased use of rescue inhaler
B) Clear sputum production and normal oxygen saturation
C) Chest pain and shortness of breath with exertion
D) Mild headache and dizziness
The nurse is assessing a client who is taking corticosteroids for asthma. Which of the following findings would be most concerning?
Increased appetite and weight gain
B) Decreased energy and difficulty sleeping
C) Signs of infection and delayed wound healing
D) Sudden onset of dizziness and nausea
The nurse is assessing a client who has been admitted for acute pancreatitis. Which of the following findings is most likely?
Severe upper abdominal pain and nausea
B) Constipation and fever
C) Right lower quadrant pain and vomiting
D) Decreased appetite and weight loss
The nurse is assessing a client with cirrhosis. Which of the following findings is most concerning?
Jaundice, ascites, and confusion
B) Mild fatigue and weight loss
C) Nausea and abdominal distension
D) Elevated blood pressure and swelling in the legs
The nurse is assessing a client with a possible gastrointestinal bleed. Which of the following findings would be most concerning?
Black, tarry stools and low blood pressure
B) Abdominal bloating and constipation
C) Decreased appetite and mild fatigue
D) Pale skin and slight dizziness
The nurse is assessing a client with a suspected diagnosis of rheumatoid arthritis. Which of the following findings would be most indicative of this condition?
Joint pain, swelling, and stiffness, especially in the morning
B) Pain and swelling in the lower back and legs
C) Warmth and redness in the affected joints only after exertion
D) Sudden onset of pain with no history of joint issues
The nurse is assessing a client with a history of hypertension. Which of the following findings is most concerning?
Blood pressure of 160/95 mmHg
B) Blood pressure of 135/85 mmHg
C) Blood pressure of 120/75 mmHg
D) Blood pressure of 140/88 mmHg
The nurse is assessing a client who is experiencing an acute asthma attack. Which of the following findings would be most concerning?
Increased wheezing and difficulty breathing
B) Mild shortness of breath and occasional cough
C) Decreased oxygen saturation and use of accessory muscles
D) Cough with clear sputum and no wheezing
The nurse is assessing a client who is taking a diuretic. Which of the following findings would indicate the need for further evaluation?
Dizziness, low blood pressure, and increased urination
B) Mild swelling in the legs and slight fatigue
C) Increased thirst and dry mouth
D) Normal blood pressure and clear urine
The nurse is assessing a client with a possible myocardial infarction (MI). Which of the following findings is most characteristic of an MI?
Chest pain that radiates to the left arm and jaw
B) Shortness of breath and fatigue
C) Dizziness and fainting upon standing
D) Sudden headache and blurred vision
The nurse is assessing a client with a history of tuberculosis (TB). Which of the following findings would be most concerning?
Persistent cough, weight loss, and night sweats
B) Mild fever and slight cough
C) Increased appetite and normal energy levels
D) Abdominal pain and constipation
The nurse is assessing a client who is recovering from surgery. Which of the following findings is most concerning?
Mild redness at the incision site and no fever
B) Sudden increase in pain, swelling, and warmth at the incision site
C) Slight discomfort with movement and low-grade fever
D) Decreased appetite and mild fatigue
The nurse is assessing a client with a history of diabetes. Which of the following findings would indicate the need for immediate intervention?
Blood glucose level of 350 mg/dL and fruity breath
B) Blood glucose level of 100 mg/dL and normal urine output
C) Blood glucose level of 250 mg/dL with mild thirst
D) Blood glucose level of 80 mg/dL and normal energy levels
The nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings would be most concerning?
Increase in shortness of breath, wheezing, and use of accessory muscles
B) Clear sputum production and slight cough
C) Decreased appetite and weight loss
D) Normal respiratory rate and absence of wheezing
The nurse is assessing a client with a history of hypertension. Which of the following findings would be most concerning?
Blood pressure of 150/92 mmHg
B) Blood pressure of 130/85 mmHg
C) Blood pressure of 120/80 mmHg
D) Blood pressure of 125/78 mmHg
The nurse is assessing a client with chronic pain. Which of the following interventions is most appropriate for improving the client’s quality of life?
Providing a thorough pain assessment and appropriate pain management
B) Encouraging the client to ignore the pain and focus on daily activities
C) Reducing medication use and suggesting exercise as the primary treatment
D) Teaching relaxation techniques and sending the client home
The nurse is assessing a client with chronic pain. Which of the following findings is most concerning?
Reports of increased pain despite use of prescribed analgesics
B) Mild discomfort and occasional headaches
C) Mild swelling and pain in the joints
D) Slight nausea and tiredness after long periods of activity
The nurse is assessing a client with a suspected pulmonary embolism (PE). Which of the following findings is most indicative of this condition?
Sudden onset of sharp chest pain and shortness of breath
B) Mild headache and dizziness
C) Increased appetite and weight loss
D) Persistent cough and fatigue
The nurse is assessing a client with a history of chronic bronchitis. Which of the following findings is most indicative of an exacerbation?
Increased sputum production, cough, and shortness of breath
B) Clear sputum production and occasional coughing
C) Mild fever and mild cough
D) Chest tightness and mild wheezing
The nurse is assessing a client with a history of hypothyroidism. Which of the following findings would most concern the nurse?
Weight gain, fatigue, and cold intolerance
B) Decreased appetite and weight loss
C) Increased thirst and frequent urination
D) Rapid heartbeat and tremors
The nurse is assessing a client with a history of liver disease. Which of the following findings would be most concerning?
Jaundice, ascites, and confusion
B) Nausea and vomiting with mild abdominal pain
C) Mild fatigue and loss of appetite
D) Abdominal bloating and occasional shortness of breath
The nurse is assessing a client who is recovering from surgery. Which of the following findings would be most concerning?
Sudden increase in pain and warmth at the surgical site
B) Mild swelling and redness at the incision site
C) Slight fever and occasional discomfort
D) Mild soreness at the incision site
The nurse is assessing a client with pneumonia. Which of the following findings is most indicative of pneumonia?
Cough with green sputum, fever, and difficulty breathing
B) Decreased appetite and mild fatigue
C) Clear sputum and a dry cough
D) Mild chest pain and fatigue
The nurse is assessing a client with a history of diabetes mellitus. Which of the following findings is most concerning?
Blood glucose of 380 mg/dL, fruity breath, and vomiting
B) Blood glucose of 120 mg/dL and normal energy levels
C) Blood glucose of 250 mg/dL and increased thirst
D) Blood glucose of 80 mg/dL and increased appetite
The nurse is assessing a client with acute renal failure. Which of the following findings is most concerning?
Decreased urine output and elevated creatinine
B) Increased appetite and weight gain
C) Mild swelling and low blood pressure
D) Slight fatigue and nausea
Questions and Answers for Study Guide
Describe the steps in performing a thorough nursing assessment of a client presenting with chest pain. Include the importance of each step and how the findings can guide nursing interventions.
Answer:
A thorough nursing assessment of a client presenting with chest pain involves several critical steps:
- History of Present Illness (HPI):
- The nurse should begin by gathering detailed information about the chest pain, including its onset, duration, intensity, and location. The nurse should also assess the quality of the pain (sharp, dull, or pressure-like) and any associated symptoms such as shortness of breath, nausea, or sweating. This helps differentiate between cardiac and non-cardiac causes.
- Medical and Family History:
- A review of the client’s medical and family history, particularly for cardiovascular diseases, hypertension, diabetes, and high cholesterol, is crucial in identifying risk factors for myocardial infarction (MI) or other cardiac events. This helps the nurse to anticipate possible complications and plan care accordingly.
- Physical Examination:
- The nurse should conduct a thorough physical examination to assess vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation. Physical signs such as cyanosis, edema, or diaphoresis can indicate severe distress or complications.
- The nurse should also auscultate the heart and lungs to listen for abnormal heart sounds (e.g., murmurs, rubs) or adventitious lung sounds (e.g., crackles), which could suggest cardiac or pulmonary issues.
- Pain Assessment and Severity:
- Using the appropriate pain scale (e.g., 0-10), the nurse should assess the severity of the chest pain and any pain radiation. Understanding the pain’s pattern and triggers (e.g., physical activity, stress, or eating) can help identify the underlying cause.
- Laboratory and Diagnostic Tests:
- The nurse should coordinate with the healthcare team to order essential tests such as an ECG, chest X-ray, cardiac biomarkers (troponins), and a CBC to assess for potential cardiac events. These tests help confirm or rule out myocardial infarction, pulmonary embolism, or other possible causes.
- Interventions and Monitoring:
- Based on the assessment findings, the nurse should initiate appropriate interventions, such as administering oxygen, pain relief (e.g., nitroglycerin or morphine), or antiplatelet medications if a cardiac event is suspected. Continuous monitoring of vital signs and ECG is essential to detect any signs of deterioration.
This assessment helps determine the severity of the chest pain, differentiate between cardiac and non-cardiac causes, and guide prompt interventions to minimize complications and ensure patient safety.
Explain the significance of conducting a comprehensive pain assessment in a patient with chronic pain. What tools would you use, and how would you integrate the findings into the patient’s care plan?
Answer:
A comprehensive pain assessment is critical in managing patients with chronic pain. Chronic pain, by definition, persists for longer than 3-6 months and can significantly impact a patient’s quality of life. The assessment aims to understand the pain’s intensity, quality, location, and any factors that exacerbate or relieve the pain.
- Pain History:
- The nurse should begin with a detailed history of the pain. The client should describe the nature of the pain, including its onset, duration, intensity, quality (e.g., sharp, dull, burning), and radiation. The nurse should also assess what makes the pain worse or better (e.g., movement, weather changes, medication, or rest).
- Pain Rating Scales:
- One of the most commonly used tools for chronic pain assessment is the Numerical Rating Scale (NRS), where patients rate their pain from 0 (no pain) to 10 (worst pain). The Visual Analog Scale (VAS) is also commonly used, especially for patients who have difficulty with numerical scales.
- For more complex cases, the McGill Pain Questionnaire or the Brief Pain Inventory can provide a more in-depth understanding of the pain’s quality and impact on the patient’s life.
- Impact on Function:
- Understanding the impact of pain on a patient’s daily activities, sleep patterns, and emotional well-being is crucial. This aspect of the assessment helps to gauge how well the patient is coping with the pain and if it’s interfering with their work, relationships, or self-care.
- Physical and Psychological Assessment:
- The nurse should also conduct a physical exam to identify any signs of underlying conditions, such as joint deformities, muscle spasms, or tenderness in certain areas. Psychological factors such as depression, anxiety, and coping strategies should also be assessed since these can amplify the perception of pain and hinder pain management efforts.
- Pharmacological and Non-Pharmacological Treatments:
- The nurse should explore the patient’s previous experiences with pain management, including any pharmacological treatments (e.g., opioids, NSAIDs) and non-pharmacological approaches (e.g., physical therapy, acupuncture, relaxation techniques).
- This information helps guide the development of an individualized care plan, which might include adjusting medications, exploring new therapies, or incorporating complementary treatments.
- Care Plan Integration:
- Once the pain assessment is complete, the nurse should work with the healthcare team to develop a comprehensive care plan. This plan may include pharmacologic interventions (e.g., pain medication management), physical therapy, referral to pain specialists, and psychosocial support for coping with chronic pain.
- Regular reassessment of pain is necessary to ensure that interventions remain effective and that the patient’s comfort and quality of life are maximized.
Discuss the components of a neurological assessment in a patient with suspected stroke. What are the key signs and symptoms the nurse should be vigilant about, and how would these findings influence the treatment plan?
Answer:
A neurological assessment in a patient with suspected stroke is a critical step in determining the nature, severity, and location of brain injury, which directly influences treatment decisions.
- Initial Assessment and Rapid Response:
- The nurse should perform an immediate assessment using the FAST acronym (Face, Arms, Speech, Time) to quickly identify the possibility of a stroke:
- Face: Ask the patient to smile. Look for any drooping or asymmetry.
- Arms: Ask the patient to raise both arms. Note any weakness or inability to lift one arm.
- Speech: Ask the patient to repeat a simple phrase. Any slurring or difficulty speaking can be indicative of a stroke.
- Time: Note the time when symptoms began. This is crucial for treatment decisions, especially the use of thrombolytics, which are most effective if administered within a 3-4.5 hour window from symptom onset.
- The nurse should perform an immediate assessment using the FAST acronym (Face, Arms, Speech, Time) to quickly identify the possibility of a stroke:
- Level of Consciousness and Orientation:
- The nurse should assess the patient’s level of consciousness (e.g., alert, lethargic, stuporous) and orientation to time, place, and person. Any disorientation or confusion could indicate a stroke affecting the cerebral cortex or brainstem.
- Motor Function and Coordination:
- The nurse should assess for any unilateral weakness or paralysis (hemiparesis or hemiplegia). The strength of the arms and legs should be evaluated, as well as coordination and gait.
- If the patient exhibits difficulty with balance, gait, or performing tasks that require coordination, this could indicate a stroke affecting the cerebellum or basal ganglia.
- Sensory Function:
- Sensory deficits, such as numbness or tingling, especially on one side of the body, should be assessed. The nurse can use light touch, sharp/dull sensation, and proprioception tests to assess sensory loss.
- Cranial Nerve Assessment:
- Cranial nerves should be assessed to identify deficits that may indicate a stroke in a specific area of the brain. For example, a patient with dysphagia or hoarseness may have damage to cranial nerves IX and X, which are involved in swallowing and speech.
- Reflexes and Babinski Sign:
- The nurse should check for abnormal reflexes (e.g., hyperreflexia or the absence of reflexes) and assess the Babinski sign. An abnormal Babinski response (dorsiflexion of the big toe) can indicate upper motor neuron damage.
- Vital Signs and Monitoring:
- Monitoring blood pressure, heart rate, and oxygen saturation is essential. Elevated blood pressure is common in stroke patients and may need to be managed to reduce the risk of further brain injury.
- Diagnostic Testing and Imaging:
- Once a stroke is suspected, the nurse should facilitate prompt imaging, such as a CT scan or MRI, to determine the type of stroke (ischemic or hemorrhagic) and the location of the damage. This will guide treatment decisions such as the use of tPA (tissue plasminogen activator) for ischemic stroke or surgery for hemorrhagic stroke.
- Interventions and Care Plan:
- The nurse plays a key role in initiating interventions based on the type of stroke. For ischemic stroke, the treatment goal is to restore blood flow quickly, often through thrombolytics or mechanical thrombectomy. For hemorrhagic stroke, controlling the bleeding and stabilizing the patient is the priority.
- The nurse should also provide emotional support, educate the patient and family about stroke recovery, and assist with rehabilitation planning.
In conclusion, the nurse’s prompt and comprehensive neurological assessment is critical in diagnosing stroke, determining its severity, and facilitating rapid treatment. The information gathered will directly influence the patient’s treatment plan, including thrombolytic therapy, surgical intervention, and post-stroke rehabilitation.
Explain the importance of performing a comprehensive abdominal assessment in a patient with gastrointestinal symptoms. What specific techniques would the nurse use, and how would the findings affect the care plan?
Answer:
A comprehensive abdominal assessment is vital for identifying underlying gastrointestinal (GI) issues and forming an effective care plan. It involves systematic steps to detect potential causes of abdominal pain, bloating, nausea, vomiting, or changes in bowel habits. The following components of the assessment are essential:
- Inspection:
- The nurse should begin by inspecting the abdomen for any signs of abnormality, such as distension, asymmetry, or visible masses. Any scars or surgical sites should also be noted. The skin should be assessed for jaundice (yellowing) or bruising (which may indicate bleeding or liver issues).
- Auscultation:
- After inspection, the nurse auscultates the abdomen for bowel sounds. Bowel sounds may be normal, hyperactive (in cases of diarrhea or infection), or hypoactive (in cases of ileus or obstruction). The presence or absence of vascular sounds (e.g., bruits) should also be noted, which can indicate vascular abnormalities or stenosis.
- Percussion:
- Percussion is used to assess for fluid accumulation or organ size. The nurse should percuss all four quadrants of the abdomen to check for dullness (which may indicate fluid or mass) or tympany (which may indicate gas).
- Palpation:
- The nurse should then proceed with light and deep palpation to assess tenderness, masses, or organomegaly. Tenderness, especially in the right upper quadrant (which could indicate liver or gallbladder issues) or lower abdomen (which could indicate appendicitis or pelvic issues), requires further investigation.
- Assessing Pain and Tenderness:
- If the patient reports pain, it is essential to ask the patient to describe the quality, location, and intensity of the pain. Rebound tenderness or guarding during palpation may suggest peritonitis or acute abdominal conditions such as appendicitis.
- Special Tests:
- The nurse may perform special tests, such as the Murphy’s sign (for gallbladder inflammation), Psoas sign (for appendicitis), or McBurney’s point tenderness to further assess potential conditions.
- Lab Work and Imaging:
- Based on the findings, the nurse may recommend lab work such as a CBC (to assess for infection or anemia), liver function tests, or urinalysis to rule out other conditions. Imaging such as an ultrasound or CT scan may be necessary to visualize abdominal organs.
- Treatment and Care Plan:
- The results of the abdominal assessment guide treatment. For example, if the assessment suggests appendicitis, the care plan may include preparation for surgery (appendectomy), fluid resuscitation, and pain management.
- If GI bleeding is suspected, the nurse would prioritize monitoring vital signs and preparing for possible endoscopic intervention or blood transfusion.
In conclusion, performing a thorough abdominal assessment allows the nurse to detect acute and chronic conditions and tailor the care plan to address the patient’s needs, ensuring appropriate and timely interventions.
Discuss the role of the nurse in assessing a patient with a potential respiratory infection. What assessment techniques would the nurse use, and how would the findings influence the treatment plan?
Answer:
Respiratory infections are common but can range from mild to life-threatening conditions. A thorough nursing assessment is essential to identify the severity of the infection and implement an effective treatment plan.
- Health History and Symptoms:
- The nurse should begin by asking about the onset, duration, and nature of symptoms such as cough, shortness of breath, sputum production, and fever. The nurse should also inquire about the patient’s smoking history, recent exposure to infectious agents, and pre-existing respiratory conditions (e.g., asthma, COPD).
- Inspection:
- Visual inspection of the patient’s breathing pattern is crucial. The nurse should observe for signs of respiratory distress, such as tachypnea (rapid breathing), labored breathing, use of accessory muscles, or nasal flaring. Cyanosis (blue discoloration of lips or face) is a sign of hypoxia and indicates a need for immediate intervention.
- Auscultation:
- Auscultation of the lungs is key in assessing for abnormal breath sounds. Crackles (rales) may indicate fluid in the lungs, which is common in conditions like pneumonia, while wheezing may be heard in obstructive diseases such as asthma or chronic bronchitis. The nurse should also listen for decreased breath sounds, which may suggest consolidation or pleural effusion.
- Percussion:
- Percussion can help assess lung air exchange. Dullness to percussion could indicate consolidation (as seen in pneumonia) or pleural effusion, while hyper-resonance suggests air trapping, as seen in emphysema or pneumothorax.
- Vital Signs:
- The nurse should monitor the patient’s vital signs, particularly temperature, heart rate, respiratory rate, and oxygen saturation. A fever, tachycardia, and tachypnea are common signs of infection. The nurse should pay close attention to any signs of respiratory compromise, such as decreasing oxygen saturation or increased work of breathing.
- Pulse Oximetry and Arterial Blood Gas (ABG) Analysis:
- Pulse oximetry is used to assess oxygenation status. If oxygen saturation is low (less than 90%), the nurse should consider administering supplemental oxygen.
- If necessary, an ABG test can help assess the degree of respiratory acidosis or alkalosis and guide interventions such as ventilation support.
- Sputum and Diagnostic Testing:
- The nurse should assist with collecting sputum samples for microbiological analysis to identify the causative pathogen (e.g., bacterial, viral, or fungal). A chest X-ray can help identify pneumonia, tuberculosis, or other respiratory conditions.
- Patient Education and Treatment Plan:
- If the assessment suggests bacterial pneumonia, the nurse would help initiate antibiotic therapy. For viral infections like influenza, antiviral medications may be prescribed. Oxygen therapy, bronchodilators, or corticosteroids may be necessary if the patient is experiencing significant respiratory distress.
- The nurse should also educate the patient about proper cough hygiene, the importance of rest, fluid intake, and following up with a healthcare provider if symptoms worsen.
The nurse plays a crucial role in monitoring and reassessing the patient, ensuring appropriate diagnostic tests are performed, and helping to guide the patient’s treatment plan based on assessment findings.
Discuss how the nurse should assess a patient with suspected dehydration. What are the signs and symptoms to look for, and how should the nurse intervene to prevent complications?
Answer:
Dehydration is a condition that can result from fluid loss exceeding intake, leading to various physiological imbalances. Early identification and intervention are essential to prevent complications such as hypovolemic shock, renal failure, or electrolyte disturbances.
- Health History and Risk Factors:
- The nurse should begin by assessing the patient’s history, including recent fluid intake, vomiting, diarrhea, fever, or excessive sweating. The nurse should also inquire about medications (e.g., diuretics), chronic conditions (e.g., diabetes or kidney disease), or surgeries that may increase the risk of dehydration.
- Physical Assessment:
- The nurse should observe for signs of dehydration, such as dry mucous membranes, sunken eyes, and poor skin turgor. A common test for skin turgor is the “pinch test,” where the nurse gently pinches the skin on the back of the hand or forearm. In a dehydrated patient, the skin will return to its original position more slowly than usual, indicating reduced fluid volume.
- Vital Signs:
- The nurse should monitor the patient’s vital signs closely. Dehydration often causes tachycardia (increased heart rate) and hypotension (low blood pressure), which are compensatory mechanisms for fluid loss. The nurse should also assess the patient’s temperature, as a fever can contribute to fluid loss.
- Urine Output:
- The nurse should assess urine output, as decreased urine output is a key sign of dehydration. Dark, concentrated urine is indicative of insufficient fluid intake. If the patient is unable to produce adequate urine, it may suggest severe dehydration or renal impairment.
- Laboratory Tests:
- The nurse should assist with obtaining blood tests, such as a CBC, serum electrolytes (especially sodium and potassium), and blood urea nitrogen (BUN), which can help assess the degree of dehydration and any associated imbalances.
- Interventions:
- The primary intervention for dehydration is fluid replacement. The nurse should initiate oral rehydration therapy if the patient is able to tolerate it, providing fluids like water or electrolyte solutions.
- If the patient is severely dehydrated or unable to take fluids orally, the nurse may administer intravenous (IV) fluids, such as normal saline or lactated Ringer’s solution, to rapidly restore fluid balance.
- The nurse should also monitor for signs of fluid overload, especially in patients with comorbidities like heart failure or kidney disease.
- Ongoing Monitoring:
- Frequent reassessment of the patient’s hydration status is critical. The nurse should monitor intake and output, vital signs, and laboratory results to guide fluid management.
- The nurse should also provide education on preventing dehydration, such as the importance of drinking fluids regularly, avoiding excessive alcohol or caffeine, and managing conditions that contribute to fluid loss.
By performing a comprehensive assessment and intervening early, the nurse can help prevent the complications associated with dehydration and ensure the patient’s recovery.