The nurse is performing the technique shown. What is the nurse assessing?

Tactile fremitus

Chest expansion

Breath sounds

Tissue consolidation

Answer and Explanation

The Correct Answer is B

A. Tactile fremitus: This involves palpating vibrations on the chest wall as the patient speaks, not assessing chest expansion.

B. Chest expansion: This technique assesses the symmetrical movement of the chest during inhalation and exhalation, which is the correct assessment for this context.

C. Breath sounds: Breath sounds are assessed through auscultation rather than palpation.

D. Tissue consolidation: This involves detecting areas of increased density in lung tissue, often assessed through percussion or auscultation, not through the technique shown for chest expansion.

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Correct Answer is D

Explanation

A. 4+: This indicates very brisk reflexes with possible clonus, which is more than just brisk reflexes.

B. 2+: This indicates normal reflexes, not brisk.

C. 1+: This indicates diminished or hypoactive reflexes, not brisk.

D. 3+: This indicates brisk reflexes, which are faster than normal but without evidence of clonus.

A. Problem-oriented assessment B. Follow-up history C. Comprehensive assessment D. Emergency history

Correct Answer is B

Explanation

A. Problem-oriented assessment: This focuses on specific issues or symptoms rather than evaluating outcomes of an established care plan.

B. Follow-up history: This type of assessment is conducted to evaluate the effectiveness of interventions and monitor progress towards outcomes identified in the care plan.

C. Comprehensive assessment: This involves a thorough evaluation of the client’s overall health status and history, not specifically focused on evaluating outcomes.

D. Emergency history: This is conducted in urgent situations to quickly assess and address immediate issues, not for evaluating outcomes of a care plan.

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The nurse is performing the technique shown. What is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

Correct Answer is D

Explanation

The nurse who has been assigned to a client on the second shift is assessing a client to evaluate the outcomes identified in the care plan. This nurse is conducting which type of assessment?

Correct Answer is B

Explanation

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