NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?
Correct Answer: A
Rationale: The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.
Question 2 of 5
The nurse performs an Allen's test before blood is drawn from the radial artery for an arterial blood gas (ABG) assessment. This intervention is done to determine the collateral circulatory adequacy of which arterial vessel?
Correct Answer: A
Rationale: Before radial puncture for obtaining an arterial specimen for ABGs, Allen's test is performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Allen's test does not determine the adequacy of carotid, brachial, or femoral circulation.
Question 3 of 5
Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply.
Correct Answer: A,B,C,E
Rationale: The vegetative signs of depression are changes in physiological functioning that occur during depression. These include changes in appetite, weight, sleep patterns, and psychomotor activity. The remaining options represent psychological assessment categories.
Question 4 of 5
Which data should the nurse expect to obtain during the admission assessment of a child to support the diagnosis of irritable bowel syndrome?
Correct Answer: D
Rationale: Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted. Option 1 is a clinical manifestation of lactose intolerance. Option 2 is a clinical manifestation of Hirschsprung's disease. Option 3 is a clinical manifestation of celiac disease.
Question 5 of 5
A home care nurse assesses an older client's functional status and ability to perform activities of daily living (ADLs). What is the focus area of the nurse's assessment?
Correct Answer: B
Rationale:
To evaluate the client's functional status, the nurse assesses the client's ability to perform self-care or ADLs, including bathing, toileting, ambulating, dressing, and feeding. Everyday routines, household management, and physical condition are not components of functional status.