When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?

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Question 1 of 5

When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?

Correct Answer: A

Rationale: The correct answer is A: Capillary refill less than 3 seconds. This finding is considered normal and indicates good peripheral perfusion. Pitting edema (choice B) and pale nail beds (choice C) are abnormal findings that may suggest underlying health issues. Thick skin on the soles of the feet (choice D) is not an expected normal finding during a skin assessment and could be indicative of a callus or other skin condition.

Question 2 of 5

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?

Correct Answer: A

Rationale: The correct answer is A. The statement about struggling with aging parents indicates a significant stressor that could impact overall well-being and warrants further assessment. This statement reveals a potential source of emotional distress and adjustment difficulties for the client, as aging parents needing help can be a complex issue involving feelings of loss, role reversal, and increased responsibilities. Choices B, C, and D, although important, do not signify as immediate a need for further assessment compared to the challenges related to aging parents. Choice B focuses on intimate relationships, which is a common concern but may not be as urgent as dealing with aging parents. Choice C reflects feelings of selfishness but does not indicate an immediate need for further assessment. Choice D involves expectations from the client's child but does not highlight a critical issue that could impact the client's well-being as directly as struggling with aging parents.

Question 3 of 5

A guardian reports that a 4-year-old child is waking up with nightmares. Which of the following interventions should the nurse suggest?

Correct Answer: C

Rationale: The correct answer is to have the child go to bed at a consistent time every day. Consistent bedtime routines can help reduce nightmares by providing the child with a sense of security and stability. Offering a large snack before bedtime or allowing extra TV time may disrupt sleep patterns and lead to nightmares. Increasing physical activity before bedtime could have the opposite effect and make it harder for the child to fall asleep.

Question 4 of 5

A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?

Correct Answer: D

Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.

Question 5 of 5

A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

Correct Answer: A

Rationale: The correct answer is 'Assessment.' In the nursing process, assessment is the first step, crucial before any intervention. Assessment involves gathering data about the client's condition to establish a baseline for evaluating responses to interventions. In this scenario, the newly licensed nurse missed assessing the client's pain intensity, location, quality, and other relevant factors before administering the pain medication. While the follow-up evaluation with the client is commendable, it cannot replace the initial assessment. Planning involves setting goals and outcomes, intervention is the action taken to achieve these goals, and evaluation assesses the client's response to the intervention.

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