The nurse gave a client an instruction sheet for a colonoscopy. The client held the instructions approximately 18 inches from their face and read the description of the procedure aloud. The nurse recognizes that the client

Would do well on a Rosenbaum card

is likely demonstrating signs of a stroke

Requires testing for visual acuity

Understands the colonoscopy procedure

Answer and Explanation

The Correct Answer is A

A. Rosenbaum card: Holding reading material at approximately 18 inches from the face suggests that the client has near vision sufficient to perform well on a Rosenbaum test, which evaluates near visual acuity.

B. Stroke: Difficulty reading instructions is not necessarily indicative of a stroke.

C. Visual acuity: While they may not need immediate testing, their near vision appears adequate.

D. Understands procedure: While reading aloud may indicate comprehension, the focus here is on their visual ability.

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Correct Answer is B

Explanation

A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.

B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.

C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.

D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.

A. Air conduction greater than bone conduction. B. Bilateral hearing loss. C. No lateralization of vibrations. D. unilateral hearing loss.

Correct Answer is C

Explanation

A. Air conduction greater than bone conduction: This is tested with the Rinne test, not the Weber test.

B. Bilateral hearing loss: This is not a normal finding in the Weber test.

C. No lateralization of vibrations: In a normal Weber test, the vibrations are heard equally in both ears, indicating no conductive or sensorineural hearing loss.

D. Unilateral hearing loss: This would be abnormal and suggest hearing impairment in one ear.

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The nurse gave a client an instruction sheet for a colonoscopy. The client held the instructions approximately 18 inches from their face and read the description of the procedure aloud. The nurse recognizes that the client

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

Correct Answer is B

Explanation

A nurse performs the Weber test on a healthy adult client. The nurse would expect which of the following normal finding?

Correct Answer is C

Explanation

In performing a voice test to assess hearing, which of these actions would the nurse perform?

When assessing the pupillary light reflex or PERRL (pupils, round, reactive to light), the nurse should use which technique?

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate?

A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:

A patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate?

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?

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?