The nurse is performing a neurological assessment on a client with a history of Diabetes.

When testing the ability to feel the vibrations of a tuning fork, the nurse notices that the client is unable to feel vibrations on the great toe or ankle bilaterally, but is able to feel vibrations on both patellae. What should the nurse suspect from these assessments?

Hyperalgesia

Peripheral neuropathy

Hyperparalysis

Lesion of the sensory cortex

Answer and Explanation

The Correct Answer is B

A.   Hyperalgesia refers to increased sensitivity to pain stimuli, not specifically related to the inability to feel vibrations.
B.   Peripheral neuropathy, a common complication of diabetes, often leads to sensory deficits, especially in distal extremities like the toes and feet.
C.   Hyperparalysis is not a recognized term in neurology.
D.   A lesion of the sensory cortex would likely present with broader sensory deficits rather than a specific loss of vibration sensation in the distal lower extremities.

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Correct Answer is B

Explanation

A. The Glasgow Coma Scale assesses a patient's level of consciousness, not specifically limb weakness.
B. A complete neurological examination would involve assessing cranial nerves, motor and sensory functions, reflexes, coordination, and gait, which are essential when a client presents with unilateral weakness in the arm and leg.
C. A muscular examination might focus more on muscle strength and tone but might not cover the breadth of neurological assessment needed in this scenario.
D. Neurologic recheck examination suggests a reassessment after an initial neurological exam but doesn’t specify the need for a comprehensive evaluation.

A. Bone spur B. Crepitation C. Tendonitis D. Fluid in the knee joint

Correct Answer is B

Explanation

A. A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B. Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C. Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D. Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the clinic and reports having weakness in the left arm and leg for the past week. The nurse should perform which type of neurological exam?

Correct Answer is B

Explanation

A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

Correct Answer is B

Explanation

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?

The nurse is assessing a client's joint for range of movement after falling in the shower. The nurse asks the client to move the right arm away from the center of the body. The nurse correctly documents the joint movement as?

The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

A nurse is educating a client about blood cell formation in the body. The nurse documents the education and refers to blood cell formation as?

The student nurse is studying the functioning of the nervous system. Which of the following descriptions of the central nervous system is accurate?

A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:

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The nurse is preparing to complete a muscle strength assessment on a client. Which of the following assessment techniques should the nurse utilize?