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Patient Data

Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.

Brudzinski reflexes

Muscle tone

Romberg's test

Level of consciousness

Pupil size

Cranial nerves

Glasgow coma scale

Answer and Explanation

Correct Answer : B,C,D,E,F,G

A.   Brudzinski reflexes test is primarily used to assess for meningeal irritation, which is not directly related to stroke.
B.   Muscle tone assessments help to identify abnormalities in motor function, which could indicate neurological damage. Given the patient’s history and the recent fall, muscle tone should be checked for any signs of weakness or spasticity.
C.   This test evaluates the client’s balance and proprioception. It is a quick way to check for potential issues with the nervous system, such as ataxia or other motor impairments, which could be present in a client with a stroke.
D.   Assessing the level of consciousness is critical in a neurological assessment to ensure that the client is oriented and alert, which is especially important after a fall or stroke-like symptoms.
E.   Pupillary response is an essential part of a neurological exam. Checking the size and reactivity of the pupils helps to assess brainstem function and overall neurological health.
F.   Cranial nerve function should be assessed to evaluate for signs of neurological deficits. In stroke patients, cranial nerve impairments can provide important diagnostic information.
G.   The Glasgow Coma Scale (GCS) is a standard tool for assessing the level of consciousness and neurological status. It can provide valuable insights into the severity of a neurological condition, especially in post-fall or post-stroke patients.

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Correct Answer is D

Explanation

A. This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B. This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C. Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D. This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

A. Sudden onset of severe anxiety, fear, and concern. B. Periumbilical pain localizing to right lower quadrant. C. Diffuse abdominal pain with elevated neutrophil count. D. Anorexia progressing to nausea, vomiting, and fever.

Correct Answer is B

Explanation

A. While anxiety and fear can accompany many medical conditions, they are not typically associated with appendicitis. Appendicitis is characterized by physical symptoms like pain and digestive disturbances rather than emotional symptoms.
B. Periumbilical pain that shifts to the right lower quadrant is the classic presentation of appendicitis. As the inflammation progresses, pain tends to move from the mid-abdomen to the lower right abdomen, which supports a diagnosis of appendicitis.
C. Diffuse abdominal pain is less specific and could indicate a variety of conditions. While an elevated neutrophil count can suggest infection or inflammation, the localized pain seen in appendicitis is a more distinguishing feature.
D. These symptoms are also common in appendicitis, as it typically presents with loss of appetite, nausea, and fever. However, the hallmark symptom is localized pain, particularly in the right lower quadrant, making B a stronger indication.

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Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Correct Answer is B

Explanation

An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect this client's sleep?

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

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

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range: Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Patient Data

Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.