A nurse is caring for a 73-year-old male client in an assisted living facility. The client has a history of a left-sided stroke and is experiencing increasing weakness and a decrease in range of motion (ROM) on the right side. The nurse begins the assessment at 0700hrs.

Exhibits

Based on the exhibits provided, what type of range of motion was being assessed for each joint? Select one response per row.

Elbow

Wrist

Shoulder

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"}}

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Correct Answer is C

Explanation

Choice A rationale
Hypotonic tone of the anal sphincter is an abnormal finding and may indicate neurological or muscular disorders affecting the sphincter control.
Choice B rationale
A dimpled area above the anus can be a sign of a congenital condition such as a pilonidal sinus or other abnormalities.
Choice C rationale
Increased pigmentation and coarse skin around the anus are normal findings and are due to the natural variation in skin texture and color in this area.
Choice D rationale
A flap of tissue at the sphincter, also known as a skin tag, can be a normal finding but may also indicate previous hemorrhoids or other conditions.

A. Painful symptoms alleviated by warmth. B. Cool, pale skin below the knees. C. Decreased pain when legs are elevated. D. Deep, continuous pain in the calf muscles.

Correct Answer is C

Explanation

Choice A rationale
Painful symptoms alleviated by warmth are more indicative of conditions such as arthritis or muscle strain rather than venous insufficiency.
Choice B rationale
Cool, pale skin below the knees is more indicative of arterial insufficiency rather than venous insufficiency.
Choice C rationale
Decreased pain when legs are elevated is a common symptom of venous insufficiency. Elevating the legs helps reduce venous pressure and alleviate symptoms such as swelling and aching.
Choice D rationale
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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?

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

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?

While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

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. How should the nurse expect the ear to appear when performing an otoscopic examination?

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?

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?