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While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

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

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

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 observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client’s electronic medical record (EMR)?

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?

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?

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?

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor.

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?

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