A 58-year-old patient is going home today. The nurse does her final assessment of the patient. Which of the following would be considered a normal finding?

Bowel sounds 5-30 per minute.

Capillary refill of greater than 3 seconds.

Respiratory rate of 25

Heart rate of 10

Answer and Explanation

The Correct Answer is C

The normal range for respiratory rate in adults is typically between 12 to 20 breaths per minute, butsome individuals may have a slightly higher or lower respiratory rate within the normal range.

Options a and b are incorrect. Bowel sounds of 5-30 per minute are within the normal range, but this finding alone does not indicate that the patient is ready to go home. Capillary refill of greater than 3 seconds is considered abnormal and may indicate poor peripheral perfusion.

Option d is also incorrect. A heart rate of 10 is extremely low and would be considered bradycardia. This could indicate an underlying medical issue and would require further assessment and intervention before the patient is discharged.

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Correct Answer is D

Explanation

The motor system refers to the parts of the nervous system that control voluntary movements, including the muscles, nerves, and brain. Rapid alternating movements are movements that require the coordination of multiple muscle groups, such as tapping fingers or rotating the wrist. By observing the patient's ability to perform these movements, the nurse can assess the integrity and function of the motor system.

A. As the nurse dims the lights in the room, the client’s pupils dilate. B. As the nurse checks for accommodation, the pupils remain dilated. C. The clients far vision acuity is 20/20 bilaterally. D. The client exhibits a symmetrical pupillary light reﬂex response.

Correct Answer is ["B","E"]

Explanation

A. Dilated pupils in response to dimmed lights are a normal response and not an indication of a

vision problem.

B. Pupils that remain dilated during an accommodation test indicate that the client may have an

issue with their autonomic nervous system and is not able to adjust their pupil size appropriately.

C. Far vision acuity of 20/20 bilaterally indicates normal vision.

D. A symmetrical pupillary light reﬂex response is a normal finding and not an indication of a vision

problem.

E. Frowning and squinting while reading the Snellen chart may indicate that the client is having difficulty seeing the letters clearly and may have a vision problem.

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A 58-year-old patient is going home today. The nurse does her final assessment of the patient. Which of the following would be considered a normal finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing the patient’s ability to perform rapid altering movements, the nurse is observing the:

Correct Answer is D

Explanation

The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client is experiencing a vision problem? (Select all that apply)

Correct Answer is ["B","E"]

Explanation

The nurse would use which of the following skills first when examining the cardiovascular system of a patient?

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