The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as normal finding for this age group?

Hematuria.

Enuresis.

Anuria.

Dysuria.

Answer and Explanation

The Correct Answer is B

Enuresis. Enuresis is the involuntary discharge of urine after the age at which bladder control should have been established. It is a normal finding for children up to the age of 5 years. Hematuria, Anuria, and Dysuria are abnormal findings related to the urinary system and are not normal findings for a 3-year-old.

Choice A, Hematuria, is incorrect because it is an abnormal finding related to the urinary system.

Choice C, Anuria, is incorrect because it is an abnormal finding related to the urinary system.

Choice D, Dysuria, is incorrect because it is an abnormal finding related to the urinary system.

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Correct Answer is A

Explanation

Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.

Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.

Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.

Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.

A. Have the client close their eyes, lightly rub fingers together 12 inches away from the ear, and have the client identify which side the sound is heard. B. First, place the tuning fork on the mastoid process behind the ear. When the client states the sound is no longer heard, place the tuning fork beside the ear. C. Strike the tuning fork and place it in the center of the skull. D. Stand three feet away and have the client repeat back what you have whispered.

Correct Answer is B

Explanation

In the Rinne test, the nurse first places a tuning fork on the mastoid process behind the ear, and when the client states that the sound is no longer heard, the tuning fork is placed beside the ear. This test is done to compare bone conduction with air conduction. When sound is no longer heard via bone conduction, the sound will still be heard via air conduction.

Choice A is incorrect because it describes the Weber test, not the Rinne test.

Choice C is incorrect because it is not a standard hearing test.

Choice D is incorrect because it describes the Whisper test, which is also used to test for hearing loss.

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The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as normal finding for this age group?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

Correct Answer is A

Explanation

The client is undergoing a tuning fork test to assess for hearing conduction. The nurse performs a Rinne test. How will this test be performed?

Correct Answer is B

Explanation

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