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

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?

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

In assessing a client’s neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

The nurse examines a client’s right great toe.The joint is red, edematous, and very painful with limited range of motion. The client’s serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Which assessment finding supports the client statement, “My feet swell all the time?”

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?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?