When assessing a client for vertigo, which technique should the practical nurse (PN) use?

Assess orientation to person, place, and time.

Listen for changes in speech patterns.

Inquire about sensations of spinning around.

Measure blood pressure while standing.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Assess orientation to person, place, and time: Assessing orientation evaluates cognitive status and level of consciousness but does not directly address the client’s vestibular function or the sensation of vertigo. Cognitive intactness may coexist with vertigo and is not specific for this symptom.

B. Listen for changes in speech patterns: Changes in speech can indicate neurological deficits such as dysarthria or stroke. While relevant for a general neurological assessment, speech patterns do not provide information about the inner ear or vestibular disturbances that cause vertigo.

C. Inquire about sensations of spinning around: Vertigo is characterized by the subjective perception of movement or spinning, either of the environment or the person, often related to vestibular dysfunction. Asking the client to describe these sensations directly assesses the hallmark symptom of vertigo and helps differentiate it from other causes of dizziness or imbalance.

D. Measure blood pressure while standing: Orthostatic hypotension can cause lightheadedness or dizziness but is distinct from true vertigo. While assessing for positional changes in blood pressure is important for syncope evaluation, it does not directly assess the spinning or rotational sensations characteristic of vertigo.

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Correct Answer is C

Explanation

Rationale:

A. Request the client to reach for a spoon on the breakfast tray: Reaching for objects evaluates coordination and fine motor skills more than gross muscle strength. While it can provide some information, it is not a standardized or reliable method to assess upper extremity strength.

B. Tell the client to touch themself on the nose with a forefinger 5 times: This maneuver, known as the finger-to-nose test, assesses coordination, proprioception, and cerebellar function. It does not provide an accurate measure of muscle strength in the upper extremities.

C. Have the client use both hands to grip and squeeze the PN's hands: Handgrip strength testing is a direct, objective method to evaluate upper extremity muscle strength. By having the client squeeze the PN’s hands, the nurse can compare bilateral strength and identify weakness that may indicate neurologic impairment following a TIA.

D. Ask the client to extend both arms to the side and move in small to larger circles: This movement tests range of motion and coordination rather than strength. It is useful for assessing motor control but does not quantify or reveal muscle weakness effectively.

A. Pleural friction rub. B. Wheezing. C. Coarse rhonchi. D. Stridor.

Correct Answer is A

Explanation

Rationale:

A. Pleural friction rub: A pleural friction rub is a low-pitched, dry, grating sound heard during both inspiration and expiration. It occurs when inflamed pleural surfaces rub together and is usually not cleared by coughing. It often indicates pleuritis or other conditions causing pleural inflammation and may be associated with pain during deep breaths.

B. Wheezing: Wheezing is a high-pitched, musical sound usually heard during expiration and sometimes inspiration, caused by narrowed airways due to bronchospasm, inflammation, or obstruction. It differs from a pleural friction rub in pitch, timing, and origin, and is often associated with asthma or COPD.

C. Coarse rhonchi: Coarse rhonchi are low-pitched, rattling lung sounds caused by secretions in larger airways. They may change or clear with coughing, unlike pleural friction rubs, which are persistent and unaffected by coughing.

D. Stridor: Stridor is a harsh, high-pitched sound heard primarily during inspiration and is caused by upper airway obstruction. It is distinct from a pleural friction rub in both location and mechanism, indicating obstruction rather than pleural inflammation.

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When assessing a client for vertigo, which technique should the practical nurse (PN) use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is performing daily assessment of a client who is admitted for a transient ischemic attack (TIA). Which technique should the PN implement to evaluate the client's upper extremity strength?

Correct Answer is C

Explanation

The practical nurse (PN) is auscultating the lung fields of a client exhibiting a low-pitched, grating sound during inspiration and expiration. The PN notes that coughing does not clear the sound. Which term best describes this lung sound?

Correct Answer is A

Explanation

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