Question

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Answer 1

Correct Answers:

Stage II

Rationale :

🎯A Stage II pressure ulcer is characterized by partial-thickness skin loss involving the epidermis and/or dermis.

🎯The presence of blister-like appearance, erythema, and serosanguineous drainage confirms skin is broken, but without exposure of subcutaneous tissue, muscle, or bone.

🎯This stage reflects an open, shallow ulcer with a red-pink wound bed and no slough.

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Answer 2

Correct Answers:

Evaluate the client's responses to treatment.

Rationale :

📌The primary purpose of vital signs assessment is to evaluate physiological status and monitor treatment effectiveness.

📌Changes in temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation provide real-time feedback on how the body is responding to illness, stress, or interventions, allowing timely adjustments in care.

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Answer 3

Correct Answers:

Perform a random blood sugar test.

Rationale :

✍Acanthosis nigricans (darkened, velvety skin) around the neck and axillae, especially in conjunction with fatigue, thirst, and frequent urination, suggests insulin resistance or undiagnosed diabetes mellitus.

✍Performing a random blood glucose test provides immediate data to support early diagnosis and intervention, reducing the risk of long-term complications.

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Answer 4

Correct Answers:

End-stage renal disease

Rationale :

📌Pitting edema is a classic clinical manifestation of fluid volume excess, which occurs when the body retains more fluid than it excretes.

📌 In end-stage renal disease (ESRD), the kidneys lose their ability to effectively filter blood and remove excess water, sodium, and metabolic waste.

📌This impaired filtration leads to accumulation of fluid in the interstitial spaces, especially in dependent areas such as the lower extremities.

📌Bilateral pitting edema in a client with ESRD is a result of sodium and water retention, hypoalbuminemia, and decreased renal excretion.

📌It is also a marker of worsening renal function, which may require adjustments in dialysis, fluid restriction, or medication management (e.g., diuretics, if residual function exists).

📌Monitoring for pitting edema in clients with ESRD is critical because it reflects not only volume overload but also increases the risk of hypertension, pulmonary edema, and heart failure.

📌Early detection allows the nurse to intervene by notifying the provider, restricting fluids, or evaluating dialysis efficacy.

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Answer 5

Correct Answers:

In the midline, a few centimeters behind the tip of the mandible.

Rationale :

✍The submental lymph nodes are located in the midline, just behind the mandibular symphysis (tip of the jaw).

✍These nodes drain lymph from the central lower lip, floor of the mouth, apex of the tongue, and anterior oral cavity structures.

✍ During head and neck assessment, proper localization of lymph nodes is essential to detect signs of infection, inflammation, or malignancy.

✍Palpating in the correct anatomical location allows the nurse to detect enlargement, tenderness, or firmness, which may indicate pathology in the areas these nodes serve.

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Answer 6

Correct Answers:

Distant vision.

Rationale :

⚫The Snellen eye chart is designed to assess distant visual acuity by having the client stand 20 feet away and read lines of letters decreasing in size.

⚫This test evaluates the client’s ability to see and focus on objects far from the eyes, making it effective in screening for refractive errors such as myopia (nearsightedness).

⚫ Identifying distant vision deficits helps guide further evaluation and referral for corrective lenses, preventing complications related to safety, reading signs, or driving.

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Answer 7

Correct Answers:

Formal hearing test.

Rationale :

♦Prolonged use of ototoxic antibiotics, such as aminoglycosides (e.g., gentamicin), places the client at risk for sensorineural hearing loss.

♦A formal audiological evaluation is the most accurate way to detect subtle or early hearing changes.

♦Early detection is crucial because ototoxicity can be permanent and progressive.

♦Identifying hearing loss early allows the healthcare team to discontinue or adjust the dosage of the offending agent, preventing long-term auditory impairment and preserving communication ability and quality of life.

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Answer 8

Correct Answers:

To gather information about the health status of the client

Rationale :

👉The primary purpose of a health assessment is to obtain baseline and comprehensive data about a client’s physical, psychological, and social status.

👉This foundational information allows the nurse to form clinical judgments, plan individualized care, and detect actual or potential health problems.

👉The data gathered through subjective interviews and objective exams guide the development of a personalized, evidence-based care plan and support effective communication across the healthcare team.

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Answer 9

Correct Answers:

Level of consciousness.

Rationale :

▶The client's ability to respond appropriately and remain oriented is a measure of level of consciousness (LOC), which reflects cerebral cortex function and is a sensitive indicator of neurological integrity.

▶ In the general survey, assessing LOC provides insight into the client’s ability to interact, understand, and follow commands.

▶LOC changes can signal neurological decline, trauma, hypoxia, or metabolic disturbances, prompting immediate intervention.

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Answer 10

Correct Answers:

Chronic Pain

Rationale :

🔵Pain that persists for more than 3 to 6 months is classified as chronic.

🔵The client’s report of bilateral knee pain lasting 11 months confirms that it is ongoing and unresolved, characteristic of chronic conditions such as osteoarthritis or degenerative joint disease.

🔵Chronic pain affects physical mobility, mood, sleep, and quality of life, and requires a multimodal, long-term management approach including medications, physical therapy, and possibly lifestyle modification or behavioral strategies.

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QLexNursing

2 : The nurse knows the importance of assessing vital signs is to:

3 : A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae(Acanthosis Nigricans). What would the nurse do next?

4 : In which disease process should a nurse expect to see a patient with the presence of pitting edema?

5 : The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

6 : What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

7 : A client has been receiving intravenous antibiotics (ototoxic) for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?

8 : The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

9 : Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?