In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Instruct the client to close both eyes.

Cover the client with a warmed blanket.

Darken the client's room environment.

Measure the client's body temperature.

Answer and Explanation

The Correct Answer is A

A.   Instructing the client to close their eyes is crucial during sensory assessments, including temperature testing. This helps ensure that the client does not rely on visual cues to determine the temperature of
the stimuli, allowing the nurse to accurately assess the client’s sensory perception based purely on
touch and temperature differences.
B.   Covering the client with a warmed blanket is not necessary for assessing temperature perception. This action could alter the client’s baseline sensory perception by affecting their skin temperature, which could lead to inaccurate results. The sensory assessment requires the client to experience temperature changes directly on their skin without external influences like additional warmth.
C.   Darkening the room is not relevant for assessing temperature sensation. Visual impairment (like darkening the room) is not related to sensory nerve function related to temperature perception, and this step does not contribute to an accurate assessment of the client's ability to perceive temperature changes.
D.   Measuring the client’s body temperature is not a direct method for assessing their sensory nerve function or temperature perception. While knowing the body temperature might be relevant for other reasons, it does not directly assess how well the client can sense temperature changes on their skin.

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Correct Answer is A

Explanation

A. A urine dipstick test is a preliminary screening tool that can quickly provide information about the presence of glucose, protein, nitrites, and leukocytes in the urine. In the context of uncontrolled diabetes with symptoms of painful urination, this test is useful for identifying signs of a urinary tract infection (UTI), which is a common complication in diabetic patients.
B. A rapid strep test is used to diagnose streptococcal infections, particularly strep throat. It is not relevant to the symptoms of frequent and painful urination and does not help in assessing diabetic complications or urinary issues.

C. Nitrazine pH strips are primarily used to assess amniotic fluid in pregnant women to determine if labor has started. They are not used for diagnosing urinary tract infections or evaluating symptoms related to diabetes.
D. A fingerstick glucose test measures blood glucose levels and is useful for assessing the client's current glycemic control. While monitoring blood glucose levels is important for managing diabetes, it does not directly address the issue of painful urination or the presence of a urinary tract infection.

A. Absent or sluggish response consistent with a lower motor neuron lesion. B. Flaccid paralysis. C. Hyperactive response consistent with an upper motor neuron disorder. D. A normal reflex

Correct Answer is C

Explanation

A. An absent or sluggish deep tendon reflex typically indicates a lower motor neuron lesion, which affects the peripheral nerves or spinal cord segments involved in reflex arc processing. Lower motor neuron lesions often result in reduced or absent reflexes, not brisk responses.
B. Flaccid paralysis is characterized by a lack of muscle tone and reflexes, which is usually associated with lower motor neuron damage. A brisk 4+ reflex response does not indicate flaccid paralysis but rather heightened reflex activity.
C. A brisk 4+ response indicates hyperactivity of the deep tendon reflexes, which is consistent with an upper motor neuron disorder. Upper motor neuron lesions, such as those resulting from a cerebrovascular accident (CVA), often lead to increased reflex responses due to disruption in the normal inhibitory signals from the brain.
D. A normal reflex response is typically classified as 2+ on a scale of 0 to 4, where 2+ is considered average or expected. A 4+ response indicates hyperactivity, which is not normal but rather indicates increased reflexes, usually associated with upper motor neuron issues.

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In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

Correct Answer is A

Explanation

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

Correct Answer is C

Explanation

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

A client is concerned about developing carpal tunnel syndrome. Which screening technique should the nurse perform to provide the client with useful information?

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

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