A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more focused neurological assessment of this client?

Talking in a loud voice.

Grimacing with movement.

Asymmetry of the client's smile.

Inability to follow directions.

Answer and Explanation

The Correct Answer is C

A) Talking in a loud voice: While this may indicate some level of distress or confusion, it does not necessarily signal a specific neurological deficit. Clients may raise their voice for various reasons unrelated to neurological issues.

B) Grimacing with movement: This could suggest discomfort or pain but is not an explicit indicator of neurological impairment. Grimacing can occur for many reasons, including musculoskeletal issues or emotional responses, and does not specifically necessitate a focused neurological assessment.

C) Asymmetry of the client's smile: This finding is significant and raises concerns about potential neurological issues, such as a stroke or Bell's palsy. Facial asymmetry may indicate weakness or dysfunction in the cranial nerves responsible for facial movement, warranting a more thorough neurological examination to assess for underlying causes.

D) Inability to follow directions: While this may point to confusion or cognitive impairment, it is a more general indicator and could result from various factors, including anxiety or lack of understanding. It does not specifically highlight a localized neurological deficit as clearly as facial asymmetry does.

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Correct Answer is D

Explanation

A) Friction rubs: These sounds are typically heard over the liver or spleen and indicate inflammation of the peritoneal surface. They are not standard findings during routine abdominal auscultation and are more specific to certain conditions.

B) Crepitus: This term refers to a crackling or popping sound often associated with joint movement or subcutaneous air and is not related to abdominal auscultation. It is not something a nurse would expect to hear when listening to bowel sounds.

C) Bruits: These are abnormal sounds that indicate turbulent blood flow, typically assessed over blood vessels rather than the abdomen itself. While they can be detected in some abdominal conditions, they are not the primary sounds expected during routine abdominal auscultation.

D) High pitched gurgling: This is characteristic of normal bowel sounds and indicates active peristalsis. High-pitched, gurgling sounds are a common finding during abdominal auscultation, reflecting the movement of gas and fluids in the intestines. This is what the nurse would expect to hear when assessing the abdomen.

A. Symmetry B. Hard nodules C. Skin texture D. Tenderness

Correct Answer is A

Explanation

A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.

B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.

C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.

D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.

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A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more focused neurological assessment of this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing the abdomen, the nurse would expect to auscultate which sounds?

Correct Answer is D

Explanation

The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse anticipate documenting?

Correct Answer is A

Explanation

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