The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is C
Explanation
A. Cranial nerves III, IV, and VIII are not involved in mouth functions; they primarily deal with eye movements and hearing.
B. Cranial nerves III, II, and VI are involved in vision and eye movement but not in mouth functions.
C. Cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal) are all tested through functions such as swallowing, speech, and movement of the tongue, which occur in the mouth.
D. Option D incorrectly lists cranial nerve I twice; cranial nerve I (olfactory) is related to the sense of smell, not the mouth.
Correct Answer is ["A","C","D"]
Explanation
A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.
B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.
C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.
D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.
E. Religion: This does not relate to the clinical findings associated with pneumonia.
F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.
G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.