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Exhibits

Which assessment(s) should the nurse conduct? Select all that apply.

Muscle tone

Level of consciousness

Cranial nerves

Brudzinski reflexes

Pupil size

Glasgow coma scale

Romberg's test

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Muscle tone: Assessing muscle tone is important to evaluate for motor deficits or neurological impairments that may have contributed to the fall or been caused by a cerebrovascular event.

B. Level of consciousness: The client’s inability to recall the events leading to the fall requires an assessment of mental status and level of consciousness to identify potential cognitive or neurological issues.

C. Cranial nerves: A cranial nerve assessment can detect focal neurological deficits indicative of stroke or other neurological conditions.

D. Brudzinski reflexes: This reflex is assessed for meningitis and would not be relevant in this scenario as the client does not exhibit symptoms such as fever, nuchal rigidity, or photophobia.

E. Pupil size: Changes in pupil size and reactivity may indicate increased intracranial pressure or other neurological changes.

F. Glasgow Coma Scale (GCS): This scale is crucial for assessing the client’s neurological status and level of consciousness, especially given the fall and dizziness.

G. Romberg's test: This test evaluates balance and proprioception, but it is less appropriate in the acute setting when the priority is to assess for neurological deficits related to the fall or potential cerebrovascular event.

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Correct Answer is D

Explanation

A. A normal reflex response does not include a positive Babinski sign.

B. An exaggerated reflex response refers to hyperreflexia, which can be seen in conditions like upper motor neuron lesions but does not specifically describe the Babinski sign.

C. Meningeal irritation would typically cause signs such as neck stiffness or photophobia, not a positive Babinski sign.

D. The extension of the great toe and fanning of other toes is a positive Babinski sign, which is abnormal in adults and typically suggests pyramidal tract disease (upper motor neuron lesion).

Correct Answer is []

Explanation

Potential Condition: Lobar pneumonia

Actions to take:

Auscultate the lungs for adventitious breath sounds
Inspect the chest for lag on the affected side

Parameters to monitor

Crackles
Respiratory rate and pulse

Rationale:

Potential Condition: Lobar pneumonia

The client presents with worsening breathing difficulty, a mild fever, elevated respiratory rate, and borderline hypoxemia, which are indicative of pneumonia. The chest X-ray order supports the suspicion of a lung infection, such as lobar pneumonia.

Actions to Take:

Auscultate the lungs for adventitious breath sounds: Lobar pneumonia often produces abnormal lung sounds, such as crackles or bronchial breath sounds, over the affected lobe. This assessment helps confirm consolidation in the lung.

Inspect the chest for lag on the affected side: Chest lag may indicate reduced ventilation of the affected lobe, a hallmark of pneumonia.

Parameters to Monitor:

Crackles: A common finding in pneumonia, crackles result from the movement of air through fluid-filled alveoli. Monitoring for resolution or worsening crackles can assess treatment efficacy.

Respiratory rate and pulse: Both are essential indicators of respiratory and cardiovascular status. An increasing respiratory rate or tachycardia may signal worsening oxygenation or sepsis.

Rationale for Incorrect Options:

Other Conditions

Pleural effusion: While it can cause respiratory symptoms, pleural effusion typically presents with dullness to percussion and diminished breath sounds, not crackles or lobar consolidation.

Atelectasis: Usually presents with diminished or absent breath sounds and often resolves with deep breathing exercises or incentive spirometry.

Acute bronchitis: This condition is associated with a productive cough, wheezing, and diffuse lung involvement, not localized findings like in lobar pneumonia.

Other Actions:

Assess for tactile fremitus: Fremitus is reduced in pleural effusion or pneumothorax, but pneumonia typically increases fremitus over the affected lobe.

Assess for muffled heart sounds: This is associated with cardiac tamponade, not pneumonia.

Assess for prolonged expiration: This is more relevant in obstructive conditions like asthma or COPD.

Other Parameters to Monitor:

Loud bronchial breathing: Although it may occur, it is less specific and not always present in pneumonia.

Cyanosis: This would indicate advanced hypoxemia, which is not present in this client (oxygen saturation is 94% on room air).

Wheezing: More commonly associated with bronchospasm or asthma, not lobar pneumonia.

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Exhibits Which assessment(s) should the nurse conduct? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes Which interpretation of this finding is accurate?

Correct Answer is D

Explanation

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

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While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

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Exhibits

Which assessment(s) should the nurse conduct? Select all that apply.