NR 306 CJE Health Assessment Benchmark W7 at Chamberlain University
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Free NR 306 CJE Health Assessment Benchmark W7 at Chamberlain University Questions
The nurse assesses the pulses of a client with peripheral vascular disease (PVD) and finds that the pulses are not palpable at the dorsalis pedis in the affected extremity. What is the nurse's next best action?
- A Palpate the posterior tibia pulse in the extremity.
- B Inspect the skin color of the toes in this leg.
- C Ask the client to pump their feet to increase circulation.
- D Document the finding as "Pedal pulses not palpable."
Explanation
Explanation
When a dorsalis pedis pulse is not palpable in a client with PVD, the nurse should immediately assess another distal pulse in the same extremity, most commonly the posterior tibial pulse, to determine whether perfusion is adequate. Many individuals normally have weak or absent dorsalis pedis pulses, so confirming circulation through an alternative site is essential before forming conclusions or documenting impaired perfusion. This step allows the nurse to evaluate the vascular status accurately and determine whether further interventions—such as Doppler assessment or provider notification—are required.The nurse reviews the history of a 65-year-old female who smokes cigarettes. What client education will the nurse prioritize with this client?
- A The need to take calcium supplements.
- B Requirement for daily aerobic exercise.
- C Designation of a health care proxy.
- D The need to eat more foods with Vitamin B.
Explanation
Explanation
Women over age 65 who smoke are at significantly increased risk for osteoporosis because smoking accelerates bone loss, reduces estrogen levels, and interferes with calcium absorption. Calcium supplementation—along with adequate vitamin D intake—is a key preventive measure to maintain bone mineral density and reduce fracture risk. Smoking plus advanced age places this client in a high-risk category for hip, vertebral, and wrist fractures, making education about maintaining adequate calcium intake a priority for preserving bone health.A nurse is asked to assess a client's stage II pressure injury. What findings would the nurse expect to see for this assessment? Select all that apply.
- A The skin has a blackened hard exudate covering the surface.
- B The skin is intact and non-blanchable.
- C The injury presents as a skin tear.
- D Tunneling is present.
- E Partial-thickness skin loss of the epidermis is evident.
- F The pressure injury is a blister.
Explanation
Explanation
E. Partial-thickness skin loss of the epidermis is evident
A Stage II pressure injury involves partial-thickness loss of skin, affecting the epidermis and possibly the dermis. The wound is shallow and open, often appearing pink or red without slough. This finding matches the definition of Stage II.
F. The pressure injury is a blister
A Stage II injury may present as an intact or ruptured serum-filled blister. Blisters occur because of separation of skin layers due to pressure and shear forces, making this a hallmark sign of Stage II pressure injuries.
During a new client interview, the nurse assesses the client's ability to perform instrumental activities of daily living (IADLs). What question should the nurse ask to determine the client's competence in this area?
- A "Are there any family situations that cause difficulty for you?"
- B "Can you explain how you shop for your necessities?"
- C "Can you tell me what your schedule was like yesterday?"
- D "What things do you do regularly to stay healthy?"
Explanation
Explanation
Instrumental activities of daily living (IADLs) include tasks that are necessary for independent living but are more complex than basic activities of daily living (ADLs). Shopping for necessities is a key IADL that involves planning, organizing, and executing a task, as well as managing transportation and money. Asking the client how they manage shopping helps assess their cognitive, physical, and financial ability to perform this IADL independently, which is important for evaluating their overall functional competence.The nurse performs the Romberg test on a client. What directions should the nurse give to the client to test for this sign?
- A "Close your eyes and walk backward in a straight line."
- B "Hold both of your arms out in front of you with your eyes closed."
- C "Stand with your feet together, arms at your side, and close your eyes."
- D "Touch both of your forefingers to your nose with your eyes closed."
Explanation
Explanation
The Romberg test evaluates balance and proprioception by removing visual input. The client stands with feet together and arms at the sides, first with eyes open and then closed. Loss of balance when the eyes close indicates a positive Romberg sign, suggesting a sensory (proprioceptive) deficit. This maneuver specifically assesses the body's ability to maintain posture without visual cues.The nurse palpates a client's carotid arteries. Which finding would the nurse need to document in the electronic health record?
- A A vibration over a vessel.
- B Equal peripheral pulses bilaterally.
- C Strong central pulses.
- D A bounding pulse after exertion.
Explanation
Explanation
A vibration felt over the carotid artery is known as a thrill, which is an abnormal finding. It indicates turbulent blood flow and may signal conditions such as carotid artery stenosis or an aneurysm. Because this finding reflects a potential cardiovascular abnormality requiring further evaluation, it must be documented promptly and clearly in the health record. Documentation ensures continuity of care and alerts the provider to investigate the cause.The nurse palpates tender, warm anterior cervical lymph nodes while assessing a client's neck. What question should the nurse ask to evaluate the finding further?
- A "Have you recently had a sore, dry, or scratchy throat?"
- B "Do you have pain in either of your ears?"
- C "Do you have any pain or stiffness in your neck?"
- D "Have you recently had a fever, dizziness, or headache?"
Explanation
Explanation
Tender, warm anterior cervical lymph nodes are commonly associated with infections in the head and neck area, such as a sore throat or upper respiratory infection (e.g., pharyngitis, tonsillitis). The nurse should ask about symptoms related to a throat infection, as this would help determine if the swollen lymph nodes are responding to local infection. Other options, such as pain in the ear or stiffness in the neck, may also be relevant but are less directly associated with this specific finding.A client with diabetes mellitus reports feeling hungry and thirsty most of the time, with the frequent need to urinate in large amounts. How should the nurse document these findings?
- A Client reports having to urinate frequently but having difficulty initiating urination.
- B Client reports signs of polyuria, anorexia, and dysuria.
- C Client reports always being hungry and urinates more than is appropriate.
- D Client reports polyuria, polydipsia, and polyphagia.
Explanation
Explanation
The classic symptoms of diabetes mellitus include polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). These symptoms are related to the body's inability to regulate glucose effectively, leading to increased blood glucose levels, fluid loss, and altered hunger signals. Documenting these symptoms helps identify possible issues with blood sugar control and provides a clear picture of the client's current state, guiding further assessment and intervention.The nurse tries to perform a health assessment on a client who is agitated and screaming. What is the best statement for the nurse to make in this situation?
- A "I am so sorry you are not feeling well right now. May I do your assessment?"
- B "I really need you to calm down so we can do your assessment."
- C "Everything will be alright; I promise I will get you pain medication when this is done."
- D "You seem really upset. Please tell me about it, and let's work through this together."
Explanation
Explanation
This response uses therapeutic communication by acknowledging the client’s emotional state, inviting expression of feelings, and offering support. When a client is agitated or screaming, the priority is to de-escalate the situation, establish trust, and understand the cause of distress before attempting an assessment. This statement validates the client's emotions and encourages dialogue, which helps reduce agitation and promotes cooperation. Options that ask the client to calm down, make promises, or rush into assessment are non-therapeutic and may worsen agitation.A client presents to the Emergency Department after falling from a skateboard. The client reports intense pain, inability to move the joint, and numbness. Upon inspection of the shoulder, the nurse notes a lack of fullness surrounding the deltoid muscle, swelling, bruising, and the rounded lateral aspect of the shoulder appears flattened. What does the nurse suspect?
- A Compartment syndrome of the shoulder joint.
- B Dislocation of the shoulder joint.
- C Subluxation of the shoulder joint.
- D Fracture of the shoulder joint.
Explanation
Explanation
A shoulder dislocation is strongly suggested by a flattened lateral contour of the shoulder, which occurs when the humeral head is displaced from the glenoid fossa. The lack of normal deltoid rounding, combined with severe pain, inability to move the joint, swelling, bruising, and possible numbness from nerve compression (often the axillary nerve), makes dislocation the most likely diagnosis. These classic signs require prompt evaluation and reduction to prevent neurovascular compromise and long-term joint instability.How to Order
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