The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?

Client reports taking an iron supplement

Client has dry heaves

The client reports eating red meat prior to the assessment

Client reports loss of appetite

Answer and Explanation

The Correct Answer is C

A.   Iron supplements typically lead to darker stools but may not necessarily present as a non-tarry black stool.
B.   Dry heaves or vomiting could potentially indicate upper gastrointestinal bleeding but not specifically correlate with non-tarry black stool.
C.   Consuming red meat can cause black stools due to its breakdown products, which is a normal finding.
D.   Loss of appetite doesn't directly relate to stool color or consistency.

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Correct Answer is D

Explanation

A. Dysfunction of the motor component of CN X (vagus nerve) and sensory component of CN VII (facial nerve) would present with different symptoms, such as difficulty swallowing and impaired taste sensation, not the observed facial asymmetry and puffing of cheeks.
B. CN XI (accessory nerve) dysfunction primarily affects the sternocleidomastoid and trapezius muscles and wouldn't cause the observed facial asymmetry.
C. Dysfunction of CN IV (trochlear nerve) leads to issues with downward and inward eye movement, not the facial asymmetry described.
D. Dysfunction of the motor component of CN VII (facial nerve) leads to facial asymmetry during expressions and difficulty controlling facial muscles, which matches the observed findings.

A. Very deep pitting indentation of legs lasts several minutes. B. Deep pitting indentation of legs lasts a few minutes. C. Mild pitting, no perceptible swelling of the legs. D. Moderate pitting: indentation of legs subsides rapidly.

Correct Answer is A

Explanation

A. 4+ edema is characterized by very deep pitting, where the indentation remains for an extended period (several minutes), indicating severe fluid accumulation in the tissue.
B. Deep pitting that lasts for a few minutes is more consistent with 2+ or 3+ edema, not the severe 4+ edema described.
C. Mild pitting with no perceptible swelling does not align with 4+ edema; this level of pitting suggests minimal fluid accumulation.
D. Moderate pitting where the indentation subsides rapidly is indicative of 2+ edema, not the profound swelling described as 4+ edema.

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The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?

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Correct Answer is D

Explanation

A client drove himself to the urgent care center for, "Legs that look like balloons and difficulty walking." The nurse assesses 4+ edema of both legs based upon which finding?

Correct Answer is A

Explanation

During a community screening event for bone density, an elderly client asked the nurse why she is an inch shorter in height. Which of the following responses by the nurse is correct?

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