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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A) Face is flushed and diaphoretic:
While flushing and diaphoresis can indicate fever, anxiety, or other conditions, they do not typically require immediate intervention unless associated with other severe symptoms.

B) Eyelids are matted and crusted:
Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, which requires treatment but not immediate emergency intervention.

C) Cornea are jaundiced:
Jaundiced corneas (scleral icterus) suggest elevated bilirubin levels and possible liver dysfunction. This finding requires prompt evaluation but is not typically an emergency requiring immediate intervention.

D) Oral mucosa is cyanotic:
Cyanosis of the oral mucosa indicates a lack of oxygen in the blood and is a sign of hypoxemia or respiratory distress. This is a critical finding that requires immediate intervention to address potential life-threatening respiratory or cardiovascular issues.

A. Expected finding. B. Cardiac enlargement. C. Benign variation. D. Cardiac atrophy. E. None F. None

Correct Answer is B

Explanation

Rationale:

A. An area of dullness extending from the 2nd to the 5th intercostal space along the left sternal border is an expected finding during a physical examination. This dullness represents the precise anatomical location of the myocardial mass beneath the chest wall, where it displaces resonant lung tissue. Because the heart is a solid organ, it produces a flat, thud-like sound compared to the hollow resonance of the surrounding lobes.

B. Cardiac enlargement, or cardiomegaly, would be indicated if the area of dullness extended lateral to the midclavicular line or shifted significantly downward. In such cases, the displaced apex would reflect ventricular hypertrophy or dilation, typically seen in chronic heart failure. Since the dullness described in the question remains within the standard 2nd to 5th intercostal boundaries, it does not suggest a pathological increase in heart size.

C. A benign variation usually refers to anatomical anomalies like dextrocardia or situs inversus, which would alter the location of dullness to the right side of the thorax. The findings provided describe a perfectly centralized and standard cardiac silhouette on the left side of the mediastinum. Therefore, characterizing this as a variation is incorrect, as it perfectly aligns with the standard clinical baseline for a healthy adult.

D. Cardiac atrophy involves a reduction in myocardial muscle mass and overall heart volume, which would likely result in a smaller area of dullness than described. This condition is often associated with severe wasting diseases or advanced aging and would cause the borders of cardiac dullness to recede inward. The measurement from the 5th up to the 2nd intercostal space represents a robust, normal heart size rather than a diminished or atrophied state.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health? Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

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