NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 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 2 of 5
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?
Correct Answer: D
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from the nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep.
Therefore, the remaining options are incorrect.
Question 3 of 5
A pregnant client diagnosed with diabetes mellitus arrives at the primary health care clinic for a follow-up visit. What best assessment should the nurse perform to assess insulin function?
Correct Answer: C
Rationale: In a pregnant client with diabetes mellitus, assessing insulin function is critical to ensure glycemic control and prevent complications. Testing urine for glucose and ketones is the best assessment, as it directly indicates whether insulin is effectively managing blood glucose levels (glucose in urine suggests hyperglycemia) and whether the client is at risk for ketoacidosis (ketones indicate fat metabolism due to insufficient insulin). Urine specific gravity reflects hydration status, not insulin function. Edema assessment is relevant for preeclampsia or fluid overload, not insulin function. Vital signs like blood pressure, pulse, and respirations provide general health information but are not specific to insulin function.
Question 4 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 5 of 5
The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. Which sign/symptom should the nurse observe with this electrolyte imbalance?
Correct Answer: B
Rationale: The inadequate production of aldosterone in clients with Addison's disease causes the inadequate excretion of potassium and results in hyperkalemia. The clinical manifestations of hyperkalemia are the result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function. Based on this information, none of the remaining options are manifestations that are associated with Addison's disease or hyperkalemia.