The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

The jugular venous pulse is visible when the client lies supine.

The jugular veins are distended when the client sits at a 45-degree angle.

The jugular venous pulse is not visible when the client is sitting upright.

The jugular veins are fully distended when the client is in a high Fowler position.

Answer and Explanation

The Correct Answer is C

Choice A reason: Visible jugular pulse supine is normal, as gravity pools venous blood. However, the question seeks upright findings. This is expected lying down, not sitting, misaligning with the healthy standard for an upright position in this context fully.

Choice B reason: Distended jugular veins at 45 degrees suggest elevated central venous pressure, like in heart failure, not health. In a healthy client, veins collapse at this angle, making this an abnormal, not expected, finding for jugular assessment here.

Choice C reason: No visible jugular pulse upright is normal in health, as venous pressure drops below the clavicle when sitting. This reflects proper heart function and gravity’s effect, aligning with expected findings in a healthy client’s neck vessel exam accurately.

Choice D reason: Full jugular distension in high Fowler’s (60-90 degrees) indicates pathology, like right heart failure, not health. Healthy veins collapse at this elevation, making this an abnormal finding, not the expected norm for jugular assessment entirely here.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Slow venous return causes edema, not deep, painful wounds. This venous issue lacks the arterial insufficiency link to tissue necrosis, misaligning with the circular ulcer’s ischemic profile, which requires oxygen delivery, not just drainage, here fully.

Choice B reason: Osmotic pressure disruption affects fluid balance, not localized wounds. This systemic issue doesn’t explain a toe ulcer’s depth and pain, missing the vascular supply deficit driving tissue breakdown in this specific extremity finding entirely and clearly.

Choice C reason: Lymphatic blockage or infection causes swelling or lymphangitis, not deep, circular wounds. This lacks the ischemic etiology of toe ulcers, which stem from arterial insufficiency, not lymphatic dysfunction, distinguishing it from the observed pathology here fully.

Choice D reason: Inadequate arterial blood supply, as in peripheral artery disease, causes deep, painful toe ulcers due to tissue ischemia. Poor oxygen delivery leads to necrosis, matching the wound’s characteristics, making this the most likely etiology accurately and precisely.

A. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. C. The nurse will ask the client to close his eyes, and will ask that he identify a familiar object placed in the client’s hand. D. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time.

Correct Answer is A

Explanation

Choice A reason: Graphesthesia tests cortical sensory function by tracing numbers on the palm with eyes closed. A right-sided stroke may impair this on the left side, making this the correct method to assess parietal lobe processing accurately here.
Choice B reason: Simultaneous bilateral touch tests extinction, not graphesthesia. This assesses neglect, not the ability to interpret shapes, missing the specific sensory integration focus needed for graphesthesia in this stroke assessment entirely and fully here.
Choice C reason: Identifying objects with eyes closed tests stereognosis, not graphesthesia. This evaluates tactile recognition, not number tracing, diverging from the precise cortical sensory skill targeted in this neurological exam for stroke effects here.
Choice D reason: Two-point discrimination tests sensory acuity, not graphesthesia. This measures point differentiation, not shape recognition, making it unrelated to assessing the parietal lobe’s interpretive ability post-stroke as intended in this scenario fully.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

The nurse is conducting a focused neurologic assessment on an 81-year-old client. What finding below is an age-related neurologic change?

A 53 year-old client was recently diagnosed with benign prostatic hypertrophy (BPH). He is fearful and states, "My good friend just died from prostate cancer and I am concerned this will happen to me." What would be the most appropriate response by the nurse?

A nurse is integrating health promotion education into the assessment of a client's mouth, nose and throat. What interview question is most likely to identify a risk factor for oral cancer?

The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

A client is admitted to the emergency room with a head injury. The client denies a previous history of seizures or head injury. What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

A client has a family history of prostate cancer and is committed to regular screening. What should the nurse teach the client about prostate-specific antigen (PSA) blood testing?

While examining a client's mouth the nurse notes the presence of fasciculations, fine tremors of the client's tongue. How should the nurse best respond to the assessment finding?