The nurse is assessing a 76-year-old client who has presented with an unintended weight loss of 10 lb over the past 8 weeks.

During the assessment, the nurse learns that the client has ill-fitting dentures and a limited intake of high-fiber foods.

What other health problem is the client at risk to develop?

Infection.

Deficient fluid volume.

Excessive intake of convenience foods.

Constipation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Infection is not directly related to weight loss, ill-fitting dentures, or limited fiber intake. The primary risks are more connected to gastrointestinal function rather than infections. While malnutrition can affect immune response, infection risk isn’t the primary concern here.

Choice B rationale

Deficient fluid volume is not a direct consequence of weight loss or dietary habits related to ill-fitting dentures. While fluid intake should be monitored, it is not the most immediate risk associated with these symptoms.

Choice C rationale

Excessive intake of convenience foods might contribute to poor nutritional status and unintended weight loss, but it is not the primary risk. The client's condition more directly influences gastrointestinal health rather than dietary habits.

Choice D rationale

Constipation is a significant risk due to limited intake of high-fiber foods. Fiber is crucial for promoting bowel movements and preventing constipation. Weight loss and ill-fitting dentures may further reduce the client's dietary fiber intake, increasing the likelihood of constipation

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Correct Answer is D

Explanation

Choice A rationale

Gently pressing the bones on the neck does not effectively test for neck rigidity, which is a common indicator of meningeal irritation or inflammation. This method may detect tenderness or bony abnormalities but not rigidity.

Choice B rationale

Moving the head toward both sides primarily assesses range of motion and flexibility. While reduced range of motion can be noted, this method doesn't specifically test for the resistance characteristic of neck rigidity.

Choice C rationale

Lightly tapping the lower portion of the neck to detect sensation tests for sensory nerve function but is not relevant to assessing muscle tone or rigidity, which is related to motor nerve and muscular response.

Choice D rationale

Moving the head and chin toward the chest is a proper technique to test for neck rigidity. This maneuver can elicit pain or resistance in cases of meningeal irritation, providing a reliable assessment for rigidity.

A. Check the equipment. B. Continue the assessment because no actions are indicated at this time. C. Document the reading because it reflects that the treatment has been effective. D. Contact the health care provider to review the care plan.

Correct Answer is A

Explanation

Choice A rationale

The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.

Choice B rationale

Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.

Choice C rationale

Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.

Choice D rationale

Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.

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Naxlex Comprehensive Predictor Exams

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Correct Answer is D

Explanation

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Correct Answer is A

Explanation

A nurse caring for a client with head trauma will be monitoring the client for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

A nurse is performing a neurological assessment on a client at home. During the assessment, the nurse notices that the client has a flat affect. Which lobe of the brain is responsible for a person's affect?

A nurse's assessment of a teenage client reveals that their shoulders are not level and that they have one prominent scapula is accentuated by bending forward. The nurse should expect to read about what health problem in the client's electronic health record?

Pressure ulcers are caused by:

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Which posture is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

A newly admitted client has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters should the nurse include? Select all that apply.