A nurse is performing a head-to-toe assessment on a patient admitted with dehydration. While assessing the skin turgor, the nurse pinches the patient’s skin on the back of the hand and notes that it returns slowly to its original position. Which of the following conditions does this finding most likely indicate?
A) Hypernatremia B) Hypovolemia C) Hypokalemia D) Hyperkalemia E) Hypermagnesemia
Rationale: Skin turgor is a clinical indicator used to assess hydration status. Diminished skin turgor, where the skin returns slowly to its original position, is commonly associated with hypovolemia or dehydration due to fluid loss. The other options are less directly related to this clinical assessment finding. Correct Answer: B) Hypovolemia
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During an assessment of a patient’s respiratory system, the nurse notes a respiratory rate of 8 breaths per minute. Which of the following interventions should the nurse prioritize?
A) Administering oxygen therapy B) Placing the patient in a high Fowler’s position C) Assisting with breathing exercises D) Notifying the healthcare provider E) Initiating CPR
Rationale: A respiratory rate of 8 breaths per minute is significantly below the normal range, indicating severe hypoventilation. Notifying the healthcare provider is the priority action to address this critical respiratory status, as it may indicate impending respiratory failure. CPR is not indicated as the patient has a respiratory rate, albeit low, and administering oxygen or positioning adjustments might be helpful but are secondary to addressing the underlying cause. Correct Answer: D) Notifying the healthcare provider
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NCLEX Review: Nursing Assessment Diagnosis
During a physical assessment, the nurse finds that a patient has unequal pupils and a drooping eyelid on one side of the face. Which cranial nerve is most likely affected?
A) Cranial nerve II (Optic) B) Cranial nerve V (Trigeminal) C) Cranial nerve VII (Facial) D) Cranial nerve IX (Glossopharyngeal) E) Cranial nerve XII (Hypoglossal)
Rationale: Unequal pupils and a drooping eyelid on one side of the face are indicative of a condition known as ptosis and anisocoria, which can be associated with dysfunction of cranial nerve VII (Facial). While other cranial nerves play roles in various functions, these specific findings are most closely associated with cranial nerve VII dysfunction. Correct Answer: C) Cranial nerve VII (Facial)
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NCLEX Questions Critical Thinking: Nursing Assessment Symptoms
A nurse is assessing a patient’s vital signs and notes a blood pressure reading of 160/90 mmHg. The patient reports feeling lightheaded and dizzy when standing up. Which nursing intervention should the nurse prioritize?
A) Administering an antihypertensive medication B) Initiating fall precautions C) Notifying the healthcare provider D) Encouraging increased fluid intake E) Assisting the patient to sit up slowly
Rationale: The elevated blood pressure coupled with symptoms of lightheadedness and dizziness upon standing indicates orthostatic hypotension. The priority nursing intervention in this situation is to prevent falls and further symptoms by instructing the patient to change positions slowly to minimize postural hypotension. While notifying the healthcare provider and monitoring blood pressure are important, immediate safety measures take precedence. Correct Answer: E) Assisting the patient to sit up slowly
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NCLEX Review: Nursing Assessment and Treatments
During a neurological assessment, the nurse assesses a patient’s Glasgow Coma Scale (GCS) score and finds it to be 8. Which finding is consistent with this GCS score?
A) Eyes open to voice, localizes pain, incomprehensible sounds B) Eyes open spontaneously, flexion withdrawal, oriented conversation C) Eyes open to pain, decorticate posturing, unintelligible sounds D) Eyes closed, no motor response, no verbal response E) Eyes open spontaneously, obeys commands, coherent speech
Rationale: A GCS score of 8 indicates severe impairment of neurological function. The specific components of this score include eyes opening in response to pain, decorticate posturing, and making unintelligible sounds. The other options represent different levels of consciousness or neurological functioning not consistent with a GCS score of 8. Correct Answer: C) Eyes open to pain, decorticate posturing, unintelligible sounds
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While assessing a patient’s abdomen, the nurse detects a pulsating, midline mass above the umbilicus. Which condition should the nurse suspect based on this finding?
A) Ascites B) Aortic aneurysm C) Diverticulitis D) Renal cyst E) Cholecystitis
Rationale: A pulsating, midline mass above the umbilicus suggests the presence of an abdominal aortic aneurysm. This finding is characteristic of an aortic aneurysm and warrants immediate attention due to the risk of rupture. While other conditions might present with abdominal masses, the specific location and pulsation point toward an aortic aneurysm. Correct Answer: B) Aortic aneurysm
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During an assessment, the nurse notes that a patient’s skin remains depressed after pinching the skin on the forearm. Which condition is most likely indicated by this finding?
A) Dehydration B) Hypervolemia C) Hypokalemia D) Hypernatremia E) Hypothermia
Rationale: Skin tenting or the skin remaining depressed after being pinched is a classic sign of dehydration. It occurs due to decreased skin turgor caused by fluid loss or insufficient fluid intake. While other conditions might contribute to altered fluid balance, skin tenting specifically points to dehydration as the primary concern. Correct Answer: A) Dehydration
NCLEX Practice Questions: Understanding Nursing Assessment and Symptoms
A nurse is conducting an assessment on a postoperative patient. The patient complains of sudden shortness of breath and chest pain. On examination, the nurse finds the patient’s skin cyanotic and diaphoretic. Which action should the nurse prioritize?
A) Administering pain medication B) Notifying the healthcare provider C) Initiating oxygen therapy D) Checking the patient’s temperature E) Assessing the patient’s blood pressure
Rationale: The sudden onset of shortness of breath, chest pain, cyanosis, and diaphoresis suggests a potential pulmonary embolism or cardiovascular compromise. The priority action is to ensure adequate oxygenation by initiating oxygen therapy to improve oxygenation while further assessment and intervention are underway. While notifying the healthcare provider and assessing blood pressure are important, immediate oxygen therapy takes precedence in addressing the patient’s acute respiratory distress. Correct Answer: C) Initiating oxygen therapy
NCLEX Questions: Focus on Medications for Nursing Assessment
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During a neurological assessment, the nurse asks a patient to stick out their tongue, and the tongue deviates to the right side. Which cranial nerve deficit is most likely indicated by this finding?
A) Cranial nerve V (Trigeminal) B) Cranial nerve VII (Facial) C) Cranial nerve IX (Glossopharyngeal) D) Cranial nerve X (Vagus) E) Cranial nerve XII (Hypoglossal)
Rationale: Deviation of the tongue to one side when asked to protrude it indicates a dysfunction of the hypoglossal nerve (cranial nerve XII). This nerve controls the movements of the tongue. While other cranial nerves have various functions related to facial sensation, movement, and swallowing, the specific finding of tongue deviation points towards cranial nerve XII impairment. Correct Answer: E) Cranial nerve XII (Hypoglossal)
Understanding Nursing Assessment: NCLEX Priority Questions
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During a physical examination, the nurse observes the patient’s gait and notes a wide-based, unsteady walk. Which condition is most likely indicated by this gait pattern?
A) Parkinson’s disease B) Multiple sclerosis C) Cerebellar dysfunction D) Peripheral neuropathy E) Muscular dystrophy Correct Answer: C) Cerebellar dysfunction
Rationale: A wide-based, unsteady gait often indicates cerebellar dysfunction. The cerebellum coordinates voluntary movements and maintains balance, and its impairment can result in an unsteady gait with a broader base. While other conditions might present with gait abnormalities, the specific description of a wide-based, unsteady walk is most consistent with cerebellar dysfunction. Correct Answer: E) Cranial nerve XII (Hypoglossal)