A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

Lack of a bowel movement in 2 days

Difficulty sleeping at night

+3 edema in the ankles.

Blanching erythema in the sacral area

Answer and Explanation

The Correct Answer is D

A.   While this can be uncomfortable and may require attention, it is not typically considered an emergency unless accompanied by severe pain, vomiting, or other concerning symptoms.
B.   Insomnia or difficulty sleeping can significantly impact a person's quality of life, but it is not usually an immediate threat to health.
C.   While it is important to assess and manage the underlying cause, it is not usually an immediate emergency unless it is accompanied by other severe symptoms like shortness of breath or chest pain.
D.   This finding suggests the early stages of pressure ulcer development, which can rapidly progress if not addressed promptly. Immediate intervention is crucial to prevent further tissue damage and complications.

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Correct Answer is C

Explanation

A. The brainstem controls basic life functions but is not primarily responsible for balance.
B. The cerebellum is directly involved in maintaining balance and coordination. Issues with the cerebellum would likely cause unsteadiness and difficulty in maintaining balance.
C. The extrapyramidal system influences motor control but is less directly responsible for balance compared to the cerebellum.
D. The thalamus acts as a relay center for sensory and motor signals but does not specifically control balance.

A. Achilles reflex, which is an expected response. B. Negative Babinski sign, which is normal for adults. C. Positive Babinski sign, which is abnormal for adults. D. Clonus, which is a hyperactive response

Correct Answer is C

Explanation

A. The Achilles reflex involves the contraction of the calf muscles, not the fanning of the toes.
B. A negative Babinski sign would show the toes curling downward, which is normal for adults, not fanning out.
C. A positive Babinski sign, where the toes fan out and the big toe dorsiflexes, is abnormal in adults and typically indicates neurologic damage or dysfunction.
D. Clonus involves repeated muscle contractions, not the fanning of the toes.

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A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

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Naxlex Comprehensive Predictor Exams

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

Which of the following would be considered an expected finding when assessing accommodation in an adult client?

When performing a physical assessment of a client's maxillary the nurse should.

While assessing the client's gait during, which of the following would indicate a need for further evaluation?

A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

The nurse should use which test to check for large amounts of fluid around the patella?

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?