The nurse performs a two-point discrimination test by applying two sterile needles lightly to the fingertips and moving the needle tips in ever-closing distances. A middle-aged adult client senses two points at a distance of 3 mm on the fingertips and 10 mm on the palms of the hands. Which interpretation of this finding is accurate?

Paresthesia.

Rebound reaction to the needle points.

Normal sensory finding.

Marginal decline in sensory function.

Answer and Explanation

The Correct Answer is C

A) Paresthesia: Paresthesia refers to abnormal sensations such as tingling, pricking, or numbness, typically without an external stimulus. The client's ability to discriminate two points at specific distances on the fingertips and palms does not indicate abnormal sensations or paresthesia.

B) Rebound reaction to the needle points: A rebound reaction would involve a delayed response or heightened sensitivity following the removal of a stimulus. This test does not measure rebound reactions but rather the ability to discriminate two separate points.

C) Normal sensory finding: The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. The fingertips typically have a higher density of sensory receptors and thus can discriminate smaller distances between two points, whereas the palms have fewer receptors and require a greater distance to discern two points.

D) Marginal decline in sensory function: The described ability to sense two points at these specific distances does not indicate a decline in sensory function. It aligns with normal findings for a middle-aged adult.

Nursing Test Bank

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Correct Answer is D

Explanation

A) Closed ended questions:
Closed-ended questions typically elicit short, specific responses and may not provide comprehensive information about the sputum's characteristics.

B) Leading questions:
Leading questions suggest a particular answer and may bias the client's response, preventing the nurse from obtaining an accurate description of the sputum.

C) Detailed questions about a symptom:
While detailed questions can be useful, they may be too specific initially and might not allow the client to freely describe their sputum in their own words.

D) Open ended questioning:
Open-ended questions encourage the client to provide more detailed and descriptive responses, allowing the nurse to gather comprehensive information about the sputum's color, consistency, amount, and other characteristics. This technique is best for obtaining a thorough and accurate description of symptoms.

A. Use a doppler to assess an audible DP pulse. B. Place a mark where DP pulse is auscultated. C. Review client's history for vascular disease. D. Assess capillary refill distal to the DP pulse.

Correct Answer is A

Explanation

A) Use a doppler to assess an audible DP pulse:
Using a doppler to assess an audible DP pulse may provide additional information about the presence or absence of the pulse, but it does not address the underlying cause of the absent pulse. It is important to first investigate potential causes, such as vascular disease, before resorting to additional assessment techniques.

B) Place a mark where DP pulse is auscultated:
Marking the location where the DP pulse is auscultated may assist with future assessments but does not address the underlying reason for the absent pulse. It is essential to determine the cause of the absent pulse before considering further interventions.

C) Review client's history for vascular disease:
Reviewing the client's history for vascular disease is the most important intervention in this scenario. Absence of a DP pulse may indicate peripheral vascular disease or other circulatory issues. Reviewing the client's history for risk factors such as diabetes, hypertension, smoking, or previous vascular problems can provide valuable information to guide further assessment and management.

D) Assess capillary refill distal to the DP pulse:
Assessing capillary refill distal to the DP pulse is important for evaluating peripheral perfusion but may not directly address the underlying cause of the absent pulse. While assessing capillary refill is a valuable assessment, reviewing the client's history for vascular disease takes precedence in determining the cause of the absent DP pulse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is D

Explanation

While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Correct Answer is A

Explanation

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.