As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon?

Mental

Physical

Spiritual

Interpersonal

Answer and Explanation

The Correct Answer is A

A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.

B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.

C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.

D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.

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Correct Answer is B

Explanation

A. Tactile fremitus: This involves palpating vibrations on the chest wall as the patient speaks, not assessing chest expansion.

B. Chest expansion: This technique assesses the symmetrical movement of the chest during inhalation and exhalation, which is the correct assessment for this context.

C. Breath sounds: Breath sounds are assessed through auscultation rather than palpation.

D. Tissue consolidation: This involves detecting areas of increased density in lung tissue, often assessed through percussion or auscultation, not through the technique shown for chest expansion.

A. XII B. V C. VII D. XI

Correct Answer is C

Explanation

A. XII: Cranial nerve XII (hypoglossal) controls tongue movements, but is not typically assessed by the technique described.

B. V: Cranial nerve V (trigeminal) is assessed for facial sensation and mastication, not the technique in question.

C. VII: Cranial nerve VII (facial) is responsible for facial expressions and is assessed by asking the client to perform various facial movements.

D. XI: Cranial nerve XI (accessory) is involved in shoulder and neck movements, not facial expressions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing the technique shown. What is the nurse assessing?

Correct Answer is B

Explanation

The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

Correct Answer is C

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

Use of tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma.

During the cardiac cycle, heart sounds correlate with events of the cycle. Which is being associated with systole?

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?