While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Explain the tests to the wife so she can interpret them for her husband.

Assess the client's ability to follow directions before proceeding with the exam.

Defer this part of the exam because the results are likely to be invalid.

Perform the tests because the client's mental status does not affect sensory status.

Answer and Explanation

The Correct Answer is B

A. Explain the tests to the wife so she can interpret them for her husband: While involving family members can be helpful in some situations, it is essential for the client to actively participate in sensory assessments. Having the wife interpret the tests may not give an accurate representation of the client’s sensory capabilities.

B. Assess the client's ability to follow directions before proceeding with the exam: Accurate sensory testing relies on the client's ability to understand and follow instructions, as well as to accurately report sensations. It is important to first evaluate whether the client can understand and follow instructions, as cognitive or memory issues may affect their ability to engage in the sensory exam. This step ensures that the assessment results are valid and reflective of the client’s true sensory function.

C. Defer this part of the exam because the results are likely to be invalid: While cognitive decline can impact the reliability of the exam, it is essential to assess the client's ability to participate and follow instructions before determining whether the sensory exam can be conducted properly. Deferring the exam without evaluation of comprehension is inappropriate.

D. Perform the tests because the client's mental status does not affect sensory status: While mental status may not directly affect the sensory pathways, the ability to follow directions and focus on the exam does influence the accuracy of the assessment. Proceeding without assessing the client's ability to participate could result in inaccurate findings.

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Correct Answer is C

Explanation

A. Capillary refill less than 3 seconds: This is considered a normal finding, indicating good peripheral perfusion. It does not correlate with clubbing, which is typically a chronic sign of systemic hypoxia rather than acute perfusion issues.

B. 3+ peripheral dependent edema: Edema is often associated with heart failure or venous insufficiency, not necessarily with clubbing. While both can occur in cardiopulmonary conditions, edema is not a direct indicator or cause of nail clubbing.

C. Oxygen saturation of 85%: This value is significantly low and indicates chronic hypoxemia, which is strongly associated with clubbing of the fingers or toes. Chronic low oxygen levels, as seen in conditions like COPD or congenital heart disease, stimulate tissue changes that result in clubbing.

D. Absent deep tendon reflexes: This finding is typically associated with neurological conditions such as peripheral neuropathy or spinal cord injury., not with hypoxia or diseases causing clubbing. It does not have a physiologic link to nailbed changes.

A. Periumbilical pain localizing to right lower quadrant. B. Anorexia a progressing to nausea, vomiting, and fever. C. Diffuse abdominal pain with elevated neutrophil count. D. Sudden onset of severe anxiety, fear, and concern.

Correct Answer is A

Explanation

A. Periumbilical pain localizing to right lower quadrant: This is a classic sign of appendicitis. The pain typically begins near the umbilicus and later migrates to the right lower quadrant (McBurney's point) as the inflammation progresses and irritates the parietal peritoneum. This localized pain pattern is a strong clinical indicator of appendicitis.

B. Anorexia progressing to nausea, vomiting, and fever: While these are common associated symptoms of appendicitis, they are nonspecific and can be seen in many gastrointestinal conditions such as gastroenteritis. Alone, they are not as definitive as localized right lower quadrant pain in confirming the diagnosis.

C. Diffuse abdominal pain with elevated neutrophil count: Diffuse abdominal pain suggests a more widespread issue, not the localized inflammation typically seen in early appendicitis. An elevated neutrophil count can suggest infection or inflammation but does not pinpoint appendicitis specifically without more localized symptoms.

D. Sudden onset of severe anxiety, fear, and concern: These symptoms may suggest a psychiatric or stress-related condition, or even a cardiac event in some cases, but they are not characteristic of appendicitis and do not support the suspicion of appendicitis.

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While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Correct Answer is C

Explanation

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Correct Answer is A

Explanation

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