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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Multiple maculopapular pustules over the forehead and chin are suggestive of acne vulgaris or possibly another dermatologic condition that may require medical intervention. If the pustules are widespread or persistent, it should be reported for further evaluation.
B. Bilateral patellar abrasions with eschar formation are common in children and are usually non- threatening unless there are signs of infection. This finding may not require immediate reporting unless the condition worsens.
C. A red, swollen, painful nodule on the upper back is likely a boil or abscess, but it’s important to consider the overall presentation and if there is a risk for systemic infection. This may not need immediate reporting unless symptoms worsen.
D. Small, white flecks on the hair shafts indicate possible head lice, which, while needing treatment,
doesn’t require immediate reporting unless there is a larger health concern associated with it.

A. "Refrain from eating or drinking for at least thirty minutes." B. "Lie in a prone position with slightly flexed knees." C. "Exhale slowly through your mouth then hold your breath." D. "Empty your bladder just prior to the examination."

Correct Answer is D

Explanation

A. The client should refrain from eating or drinking for other procedures but not specifically for an abdominal examination unless indicated for tests like ultrasounds.
B. A prone position is not necessary for an abdominal exam; lying on the back is preferred.
C. The client should not hold their breath during the abdominal exam unless asked to assist with specific maneuvers.
D. Having the bladder empty before the examination reduces discomfort and allows for better visualization of the abdominal organs.

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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

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

Correct Answer is A

Explanation

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

Correct Answer is D

Explanation

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years? (Enter the numerical value only.)

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

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?

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

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.