Nokea
Which is included only in a comprehensive assessment?
- A. Circulatory assessment
- B. Assessment of the airway
- C. Complete health history
- D. Disability assessment
Correct Answer: C
Rationale: The correct answer is C: Complete health history. In a comprehensive assessment, obtaining a complete health history is essential to gather information about the patient's past and present health conditions, including medical history, family history, social history, and current symptoms. This information helps the healthcare provider understand the patient's overall health status, identify risk factors, and develop an appropriate treatment plan. Assessing the circulatory system (A) and airway (B) are important components of a physical assessment, but they alone do not constitute a comprehensive assessment. Disability assessment (D) focuses on the functional limitations caused by a disability and is not always included in a comprehensive health assessment.
You may also like to solve these questions
The nurse is performing a mental health assessment on a 5-year-old girl. Her parents are in the middle of a bitter divorce and are worried about the effect it is having on their daughter. Which of the following might lead the nurse to be concerned about the girl's mental health?
- A. She clings to her mother whenever the nurse is in the room.
- B. She appears angry and will not make eye contact with the nurse.
- C. Her mother states that the girl has begun to ride a tricycle around their yard.
- D. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.
Correct Answer: D
Rationale: The correct answer is D because it indicates a potential concern about the girl's mental health. This behavior may suggest a difficulty in socializing with peers of her own age, which could be a sign of emotional distress or developmental issues. This is concerning in the context of her parents' bitter divorce.
A: Clinging to her mother is a common behavior for a child going through a stressful situation, so it may not necessarily indicate a mental health issue.
B: Appearing angry and avoiding eye contact could also be a normal reaction to stress or discomfort.
C: Riding a tricycle is a typical activity for a 5-year-old and may not directly relate to mental health concerns.
Which quadrant of the abdomen is tender in suspected appendicitis?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.
What is the first intervention when a client develops symptoms of shock?
- A. Administer oxygen
- B. Administer IV fluids
- C. Monitor respiratory rate
- D. Administer pain medication
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.
What should be the nurse's first action for a client who has sustained a spinal cord injury?
- A. Immobilize the spine
- B. Assess the client's airway
- C. Place the client in a supine position
- D. Encourage deep breathing
Correct Answer: C
Rationale: The correct answer is C: Place the client in a supine position. This is the first action because it helps prevent further injury to the spinal cord by maintaining alignment. Immobilizing the spine (choice A) is important but should come after placing the client in a supine position. Assessing the client's airway (choice B) is crucial but not the first action in a spinal cord injury. Encouraging deep breathing (choice D) is not appropriate as the priority is to stabilize the spine. In summary, placing the client in a supine position is the initial step to prevent worsening of the spinal cord injury, while the other choices are important but secondary actions.
A patient with chronic kidney disease (CKD) is being assessed. The nurse would expect to find which of the following symptoms?
- A. Weight loss and polyphagia.
- B. Edema and proteinuria.
- C. Hypertension and tachycardia.
- D. Hypothermia and bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Edema and proteinuria. In CKD, the kidneys are unable to filter waste products effectively, leading to fluid retention (edema) and protein leaking into the urine (proteinuria). Edema occurs due to fluid buildup from decreased kidney function. Proteinuria is a result of damaged glomeruli in the kidneys, allowing proteins to leak into the urine. Weight loss and polyphagia (excessive hunger) are not typical symptoms of CKD. Hypertension and tachycardia can occur in CKD due to fluid overload and electrolyte imbalances. Hypothermia and bradycardia are not common symptoms of CKD and would be more indicative of other conditions.