When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

Ask the client if he knows the year he married his wife.

Determine if the client can recall what he ate for breakfast.

Instruct the client to follow a three-step task.

Tell the client to repeat a series of unrelated numbers.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Asking the client if he knows the year he married his wife assesses long-term memory, not recent memory.
Choice B rationale
Determining if the client can recall what he ate for breakfast assesses recent memory but does not provide a comprehensive assessment.
Choice C rationale
Instructing the client to follow a three-step task assesses the client’s ability to process and remember recent information, providing a more thorough evaluation of recent memory.
Choice D rationale
Telling the client to repeat a series of unrelated numbers assesses short-term memory and attention, not specifically recent memory.

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Correct Answer is B

Explanation

Choice A rationale
An audible thud without pain is a normal finding when percussing the costovertebral angle (CVA) in a healthy individual. This indicates that there is no inflammation or infection in the kidneys or surrounding tissues.
Choice B rationale
Sharp, severe pain upon percussion of the CVA is a classic sign of pyelonephritis. This pain is due to the inflammation and infection of the kidney, which causes tenderness in the area.
Choice C rationale
Rebound tenderness is typically associated with peritoneal irritation, such as in cases of appendicitis or peritonitis. It is not a common finding in pyelonephritis.
Choice D rationale
Rigidity and firmness are more indicative of muscle spasms or guarding, which can occur in conditions like peritonitis or severe abdominal pain, but not specifically in pyelonephritis.

A. Inspection of head and neck is observed in a straight alignment without lateral curves. B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. C. Palpation of the spinous processes and surrounding muscles are non-tender. D. Observation of cervical range of motion reveals flexion and extension is 25 degrees.

Correct Answer is D

Explanation

A. Inspection of head and neck is observed in a straight alignment without lateral curves: A straight, well-aligned cervical spine is normal and does not indicate a need for further assessment of lifestyle habits.

B. Evaluation of cranial nerve XI (spinal accessory nerve) reveals flexion is maintained against full resistance:This indicates normal strength of the sternocleidomastoid and trapezius muscles, meaning there is no concern related to lifestyle habits.

C. Palpation of the spinous processes and surrounding muscles are non-tender: The absence of tenderness suggests that there is no acute inflammation, injury, or muscle strain, making further lifestyle inquiries unnecessary.

D. Observation of cervical range of motion reveals flexion and extension is 25 degrees:Normal cervical flexion and extension range from 45 to 90 degrees. A limitation to only 25 degrees suggests restricted mobility, which could be due to poor posture, occupational strain, prolonged screen time, or underlying musculoskeletal conditions.

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When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is B

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is D

Explanation

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client?

When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?