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While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

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?

During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years.The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

A nurse is caring for a 45-year-old male client in the emergency department who sustained a fall from a ladder. The client has a closed and displaced fracture of the right ulna and radius. The nurse is monitoring the client closely for any changes in condition.

Exhibits

Nurses’ Notes (0800 hrs)

• The client is alert and oriented to person, place, time, and situation.
• The right forearm is visibly deformed with significant swelling and bruising.
• The client reports severe pain rated 10/10, described as sharp and throbbing.
• Capillary refill in the right hand is 4 seconds.
• The skin on the right forearm is warm to the touch.
• Radial pulse is 2+ and palpable.
• The client denies any numbness or tingling in the right hand.

Vital Signs (0800 hrs)

• Temperature: 37.2°C (99°F)
• Heart Rate: 88 bpm
• Blood Pressure: 138/82 mmHg
• Respiratory Rate: 18 breaths/min
• Oxygen Saturation: 98% on room air

Diagnostic Results (0800 hrs)

• X-ray results: Closed and displaced fracture of the right ulna and radius.
• Hemoglobin: 13.5 g/dL (Reference range: 13.8-17.2 g/dL)
• White Blood Cell Count: 8,000/mm³ (Reference range: 4,500-11,000/mm³)

Provider’s Prescriptions (0800 hrs)

• 0.9% sodium chloride IV infusion at 75 mL/hr
• Morphine sulfate 2 mg IV push STAT once
• Obtain cast cart
• Neurovascular assessment every hour for the first 24 hours

A nurse is caring for a 45-year-old male client in the emergency department with a closed and displaced fracture of the right ulna and radius. Based on the exhibits provided, what is the priority nursing action at this time?

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client?

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating.
Which finding indicates an expected response when the nurse percusses the costovertebral angle?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

When evaluating a client’s rectal bleeding, which findings should the nurse document?