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 ["A","B","C"]

Explanation

A) Blood pressure 150/90: This data is objective because it is a measurable value obtained through direct observation using a sphygmomanometer. It provides a quantifiable assessment of the client's cardiovascular status and can be verified by others, making it an important piece of objective data.

B) Bowel sounds present in all 4 quadrants: The assessment of bowel sounds is objective as it involves physical examination techniques that can be observed and documented by the nurse. The presence of bowel sounds indicates gastrointestinal activity, and this finding can be consistently assessed across different healthcare providers.

C) PERRLA: The abbreviation stands for "Pupils Equal, Round, Reactive to Light and Accommodation." This assessment is objective as it involves specific, observable measurements of the client's pupils during an eye examination. It can be consistently evaluated by different healthcare professionals, ensuring reliable documentation.

D) Anxious about surgical procedure: This statement is subjective as it reflects the client's personal feelings and emotional state. While important for understanding the client's experience, it cannot be measured or observed directly by the nurse and relies on the client's self-reporting.

E) Dyspnea on exertion: While dyspnea can be observed, the phrase "on exertion" refers to the client's subjective experience of breathlessness. Although it can be assessed through observation of respiratory patterns, the experience itself is based on the client's interpretation, making it subjective data.

A. Dietary history from the patient B. BMI (Body Mass Index) C. Patient history of alcohol intake D. Patient complaint of weight loss

Correct Answer is B

Explanation

A) Dietary history from the patient: This information is subjective as it relies on the patient’s personal account of their eating habits, which may be influenced by memory or perception. It does not provide measurable data.

B) BMI (Body Mass Index): This is an objective measure calculated from a person’s height and weight. It provides quantifiable data that can be used to assess nutritional status and potential health risks associated with body weight.

C) Patient history of alcohol intake: This information is subjective as it is based on the patient’s self-report. It does not provide direct evidence and may vary depending on how the patient perceives their alcohol consumption.

D) Patient complaint of weight loss: This is also subjective data, as it relies on the patient’s perception of their weight change. It does not provide concrete measurements and can be influenced by various factors such as mood or misunderstanding of the situation.

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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

The nurse is completing their documentation for the shift. Which of the data is objective? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is B

Explanation

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