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A client reports feeling increasingly fatigued for several months, and the nurse
observes that the client's lips are pale. Which additional data should the nurse
collect based on this presentation?
A. Current alcohol and tobacco use
B. A 24-hour dietary recall
C. Use of vitamin and iron supplements
D. Daily pattern of oral hygiene practices
C. Use of vitamin and iron supplements
,The nurse is assessing a client who has experienced a sudden onset of hearing
loss in the right ear. Which finding should alert the nurse to a potentially serious
medical condition that requires further evaluation?
A. The client works in a busy office setting
B. There is no sign of associated infection
C. The client has no prior history of hearing loss
D. The hearing loss involves high frequencies
B. There is no sign of associated infection
The client reports to the nurse a recent exposure to the mumps. Which
assessment finding suggests the client has contracted the mumps?
A. Enlargement centered along the anterior lower neck region
B. Swelling anterior to the ear lobe on one side of the face
C. Generalized rounded shape of the face
D. Paralysis on one side of the face
B. Swelling anterior to the ear lobe on one side of the face
, A client states that she had a mastectomy of her left breast last year and now
experiences lymphedema. What should the nurse expect to find when examining
the client?
A. Swelling of the left arm and non-pitting edema.
B. Bilateral swelling of the arms with weakened pulses.
C. Complaints of pain when taking the blood pressure on the affected side.
D. Metastasis of cancer due to cancer being in the lymph nodes.
A. Swelling of the left arm and non-pitting edema.
What is the best nursing response to an older client who has not mentioned
incontinence during a genitourinary assessment?
A. Ask the client specifically about any leakage of urine.
B. Document that the client reports having no incontinence
C. Have the client cough and then check for urine leakage
D. Determine if the client has ever had urinary tract surgery.
A. Ask the client specifically about any leakage of urine.