During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

Subjective vertigo.

Tinnitus.

Dizziness.

Objective vertigo.

Answer and Explanation

The Correct Answer is D

A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.

B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.

C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.

D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.

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Correct Answer is C

Explanation

A. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
B. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
C. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
D. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.

A. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency B. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D. Hormonal changes causing vasodilation and a resulting drop in blood pressure

Correct Answer is C

Explanation

A. Atrophy of calf veins: Vein atrophy is not a normal aging process, although venous insufficiency is common due to other causes.

B. Narrowing of the inferior vena cava: This is not a typical age-related change.

C. Peripheral blood vessels growing more rigid: Arteriosclerosis (hardening of the arteries) is common with aging and leads to increased systolic blood pressure.

D. Hormonal changes causing vasodilation: Aging tends to cause vascular rigidity, not vasodilation, and is more likely to lead to hypertension.

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During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

Correct Answer is C

Explanation

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed?

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

Which of the following is the first important step in helping the patient to relax for the complete abdominal examination?