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When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client’s skin for which finding?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia.

Exhibits

Nurses Notes (0700hrs): The client reports feeling increasingly short of breath over the past two days. He has a productive cough with greenish sputum. He denies chest pain but mentions feeling very fatigued. The client appears anxious and is using accessory muscles to breathe. He is sitting upright in bed and leaning forward slightly. The client states he has not been able to sleep well due to the cough. He also reports a decreased appetite over the past few days.

Physical Examination Results (0700hrs): The client is alert and oriented to person, place, and time. He has a productive cough with greenish sputum. His skin is warm and dry to the touch. Breath sounds are diminished in the lower lobes with crackles heard bilaterally. The client is using accessory muscles to breathe and has a prolonged expiratory phase. His nail beds are slightly cyanotic. The client is diaphoretic and appears fatigued.

Vital Signs (0700hrs):

• Temperature: 38.3°C (100.9°F)
• Heart Rate: 110 bpm
• Respiratory Rate: 28 breaths per minute
• Blood Pressure: 140/90 mmHg
• Oxygen Saturation: 88% on room air

Which of the following actions should the nurse take first?

An adult client presents with gnawing epigastric pain.The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

While auscultating a client’s abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

The nurse performs a two-point discrimination test by applying two sterile needles lightly to the fingertips and moving the needle tips in ever-closing distances. A middle-aged adult client senses two points at a distance of 3 mm on the fingertips and 10 mm on the palms of the hands. Which interpretation of this finding is accurate?