Question

A nurse is caring for a client with redness, irritation, and photophobia in their right eye. The client stated they forgot to remove their contact lenses before falling asleep last night. How should the nurse respond?

Answer 1

Correct Answers:

"Do you still have your contact lenses currently in your eyes?"

Rationale :

👁️The nurse should first determine whether the contact lenses remain in place because continued wear can worsen corneal irritation and hypoxia.

🦠Sleeping in contact lenses increases the risk of corneal abrasion, keratitis, and infection.

🧤If the lenses remain in place, they should be removed safely according to clinical guidance while the eye is further assessed.

🚨Persistent redness, pain, discharge, photophobia, or vision changes require prompt ophthalmologic evaluation.

📌Core Message:

The immediate priority is determining whether the contact lenses remain in place because continued exposure can worsen corneal injury and infection risk.

Answer 2

Correct Answers:

The client has 20/60 vision

Rationale :

👓The first number in a Snellen result represents the client’s testing distance.

📏The second number indicates the distance at which a person with normal vision can read the same chart line.

👁️A result of 20/60 means the client sees at 20 feet what a person with normal vision sees at 60 feet.

📉This measurement indicates reduced distance visual acuity.

📌Core Message:

A Snellen result of 20/60 means the client must be 20 feet away to read what normal vision can read at 60 feet.

Answer 3

Correct Answers:

Says to the client, "I'm counting your respirations now, please remain still."

Rationale :

🌬️Clients may consciously change their respiratory rate or depth when they know respirations are being counted.

⌚The nurse should count respirations unobtrusively, often while appearing to continue assessing the radial pulse.

👀Respiratory assessment should include rate, rhythm, depth, effort, and chest symmetry.

⚠️Announcing the assessment may produce an inaccurate measurement and therefore warrants RN intervention.

📌Core Message:

Respirations should be counted without informing the client because awareness may consciously alter the respiratory pattern.

Answer 4

Correct Answers:

"This disorder is related to my skin's response to some type of environmental allergen."

Rationale :

🌿Atopic dermatitis is a chronic inflammatory condition associated with immune hypersensitivity and impaired skin-barrier function.

🌸Environmental triggers such as allergens, irritants, heat, and dry air may worsen eczema symptoms.

🧴Management includes regular moisturization, trigger avoidance, and prescribed anti-inflammatory treatment.

🔄The condition commonly produces recurring episodes of dry, inflamed, and intensely pruritic skin.

📌Core Message:

Atopic dermatitis is an inflammatory allergic skin disorder influenced by environmental triggers and impaired skin-barrier function.

Answer 5

Correct Answers:

Hoarseness of voice and difficulty swallowing

Rationale :

🗣️Persistent hoarseness may indicate dysfunction or obstruction involving the larynx, vocal cords, or recurrent laryngeal nerve.

🥣Difficulty swallowing may reflect compression, inflammation, neurologic dysfunction, or a head-and-neck mass.

🚨The combination of hoarseness and dysphagia requires further evaluation for a potentially serious airway or structural disorder.

🩺The nurse should assess respiratory status, symptom duration, weight loss, pain, and other associated warning signs.

📌Core Message:

Hoarseness accompanied by difficulty swallowing is an abnormal finding requiring evaluation for laryngeal, neurologic, or obstructive disease.

Answer 6

Correct Answers:

A 26-year-old client who is unresponsive

Rationale :

🌡️An unresponsive client cannot safely cooperate with an oral temperature measurement.

🩺A rectal temperature may provide an accurate core measurement when other routes are unsuitable and no rectal contraindications exist.

🧤The nurse must first confirm the absence of diarrhea, rectal disease, recent rectal surgery, neutropenia, thrombocytopenia, or bleeding risk.

🔍A safer alternative route may be selected if available or if rectal temperature measurement is contraindicated.

📌Core Message:

A rectal probe may be used for an unresponsive adult when oral measurement is unsafe and no rectal or bleeding contraindications are present.

Answer 7

Correct Answers:

Pulse oximeter reading

Rationale :

🌬️A respiratory rate of 30 breaths/minute indicates tachypnea.

🫁The nurse should promptly determine whether the client has impaired oxygenation by measuring oxygen saturation.

📊Pulse oximetry provides rapid, noninvasive data about arterial hemoglobin oxygen saturation.

🚨A low reading would support immediate respiratory interventions and further assessment of breathing effectiveness.

📌Core Message:

Tachypnea requires immediate evaluation of oxygen saturation to identify hypoxemia and guide respiratory intervention.

Answer 8

Correct Answers:

Blood pressure 86/42 mmHg, Heart rate 110 beats per minute

Rationale :

💧Fluid-volume deficiency reduces circulating blood volume and causes hypotension.

❤️The heart rate increases to compensate for reduced preload and maintain cardiac output.

📉A blood pressure of 86/42 mm Hg accompanied by a pulse of 110 beats/minute strongly suggests hypovolemia.

🚨Additional findings may include weak pulses, dry mucous membranes, reduced urine output, dizziness, and delayed capillary refill.

📌Core Message:

Fluid-volume deficiency commonly produces hypotension with compensatory tachycardia as the body attempts to preserve tissue perfusion.

Answer 9

Correct Answers:

Temperature

Rationale :

🌡️A temperature of 101.8°F indicates fever.

❤️Fever increases metabolic activity and oxygen demand, causing the heart rate to rise.

📊The pulse commonly increases by approximately 10 beats/minute for each 1°C increase in body temperature.

🩺The normal respiratory rate, blood pressure, and oxygen saturation are less likely to explain the client’s tachycardia.

📌Core Message:

Fever commonly contributes to tachycardia by increasing metabolism, oxygen requirements, and cardiovascular workload.

Answer 10

Correct Answers:

Decreased sense of taste

Rationale :

👅Normal aging reduces the number and sensitivity of taste buds.

🍲A decreased sense of taste can reduce appetite and affect an older adult’s nutritional intake.

👃Age-related decline in smell can further diminish the perception of food flavor.

🧂The nurse should discourage excessive salt or sugar use and promote flavorful, nutrient-dense food choices.

📌Core Message:

A decreased sense of taste is an expected age-related sensory change that may affect appetite and nutritional status.

NR 306 Exam-2 Health Assessment

No.

1 :
A nurse is caring for a client with redness, irritation, and photophobia in their right eye. The client stated they forgot to remove their contact lenses before falling asleep last night. How should the nurse respond?

3 :
The registered nurse (RN) observes a licensed practice nurse (LPN) assess a client's vital signs. What action by the LPN warrants intervention by the RN?

4 :
Which client statement indicates understanding related to characteristics of atopic dermatitis (eczema)?

5 :
The nurse is assessing a client's head, neck, and throat. Which finding should concern the nurse?

6 :
The nurse is caring for a group of clients. For which client should the nurse use a rectal temperature probe?

7 :
A nurse is assessing a client's vital signs and notes a respiratory rate of 30 breaths/minute. What data should the nurse plan to obtain next?

8 :
The nurse is assessing a client in an outpatient clinic. Which finding would be expected for a client with fluid volume deficiency?

9 :
A nurse assesses the following vital signs for a client: temperature of 101.8 F, pulse 104 beats/minute, respiratory rate 20 breaths/minute, blood pressure of 124/80 mmHg, and pulse oximetry 98% on room air. Which finding should the nurse suspect is contributing to this client's tachycardia?

10 :
Which age-related change should the nurse expect to find while assessing an older adult client?

NR 306 Exam-2 Health Assessment

No.

1 : A nurse is caring for a client with redness, irritation, and photophobia in their right eye. The client stated they forgot to remove their contact lenses before falling asleep last night. How should the nurse respond?

3 : The registered nurse (RN) observes a licensed practice nurse (LPN) assess a client's vital signs. What action by the LPN warrants intervention by the RN?

4 : Which client statement indicates understanding related to characteristics of atopic dermatitis (eczema)?

5 : The nurse is assessing a client's head, neck, and throat. Which finding should concern the nurse?

6 : The nurse is caring for a group of clients. For which client should the nurse use a rectal temperature probe?

7 : A nurse is assessing a client's vital signs and notes a respiratory rate of 30 breaths/minute. What data should the nurse plan to obtain next?

8 : The nurse is assessing a client in an outpatient clinic. Which finding would be expected for a client with fluid volume deficiency?

9 : A nurse assesses the following vital signs for a client: temperature of 101.8 F, pulse 104 beats/minute, respiratory rate 20 breaths/minute, blood pressure of 124/80 mmHg, and pulse oximetry 98% on room air. Which finding should the nurse suspect is contributing to this client's tachycardia?

10 : Which age-related change should the nurse expect to find while assessing an older adult client?

1 :
A nurse is caring for a client with redness, irritation, and photophobia in their right eye. The client stated they forgot to remove their contact lenses before falling asleep last night. How should the nurse respond?

3 :
The registered nurse (RN) observes a licensed practice nurse (LPN) assess a client's vital signs. What action by the LPN warrants intervention by the RN?

4 :
Which client statement indicates understanding related to characteristics of atopic dermatitis (eczema)?

5 :
The nurse is assessing a client's head, neck, and throat. Which finding should concern the nurse?

6 :
The nurse is caring for a group of clients. For which client should the nurse use a rectal temperature probe?

7 :
A nurse is assessing a client's vital signs and notes a respiratory rate of 30 breaths/minute. What data should the nurse plan to obtain next?

8 :
The nurse is assessing a client in an outpatient clinic. Which finding would be expected for a client with fluid volume deficiency?

9 :
A nurse assesses the following vital signs for a client: temperature of 101.8 F, pulse 104 beats/minute, respiratory rate 20 breaths/minute, blood pressure of 124/80 mmHg, and pulse oximetry 98% on room air. Which finding should the nurse suspect is contributing to this client's tachycardia?

10 :
Which age-related change should the nurse expect to find while assessing an older adult client?