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The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

Consider this a normal capillary refill time that requires no further assessment.

Consider this a delayed capillary refill time, and investigate further.

Ask the patient about a history of frostbite.

Suspect that the patient has venous insufficiency.

Answer and Explanation

The Correct Answer is B

A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.

B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.

C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.

D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.

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Correct Answer is C

Explanation

A. Air conduction greater than bone conduction: This is tested with the Rinne test, not the Weber test.

B. Bilateral hearing loss: This is not a normal finding in the Weber test.

C. No lateralization of vibrations: In a normal Weber test, the vibrations are heard equally in both ears, indicating no conductive or sensorineural hearing loss.

D. Unilateral hearing loss: This would be abnormal and suggest hearing impairment in one ear.

A. Subjective vertigo. B. Tinnitus. C. Dizziness. D. Objective vertigo.

Correct Answer is D

Explanation

A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.

B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.

C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.

D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.

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The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse performs the Weber test on a healthy adult client. The nurse would expect which of the following normal finding?

Correct Answer is C

Explanation

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

Correct Answer is D

Explanation

Which of the following should the nurse perform to assess the arterial function of the lower extremities?

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed?

A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:

During an eye examination, a client tells a nurse that their left eye feels dry and itchy and has noticed a lot of tearing. The nurse notices that the client's left lower eyelid is rolled out with exposure of the palpebral conjunctiva. The nurse would document these findings as:

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

A nurse is educating a patient regarding arterial insufficiency. The nurse knows the patient has a correct understanding of arterial risk factors by listing the following:

When assessing the abdomen most health care providers divide the abdomen into how many sections?