NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
The nurse is performing an assessment on a pregnant client with a history of cardiac disease. Which body area will venous congestion most commonly be noted in?
Correct Answer: A
Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, the vulva, or the rectum. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion. It would be difficult to assess for edema in the abdominal area of a client who is pregnant.
Question 2 of 5
A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which sign that correlates with this fluid imbalance?
Correct Answer: D
Rationale: Assessment findings with fluid volume deficit are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The assessment findings in the remaining options are not associated with dehydration.
Question 3 of 5
A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?
Correct Answer: D
Rationale: Premature rupture of the membranes is usually manifested by a sudden discharge of fluid from the vagina before 37 weeks of gestation. Miscarriage is typically manifested by vaginal bleeding and abdominal pain. Preterm labor is typically manifested by uterine contractions, cramping, and pressure before 37 weeks of gestation. Intrauterine fetal demise is usually manifested by an absence of fetal movements and heartbeat.
Question 4 of 5
On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation should the nurse expect to note?
Correct Answer: D
Rationale: Stage III Lyme disease develops within a month to several months after initial infection. It is characterized by arthritic symptoms such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. A rash occurs during stage I, and cardiac and neurological dysfunction occur during stage II.
Question 5 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.