A nurse is assisting in the care of a client in a clinic.

For each assessment finding, click to specify if the finding is consistent with peripheral neuropathy, transient ischemic attacks (TIA), or peripheral vascular disease. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Recent diagnostic results

Report of pain

Medical history

HEENT findings

Right lower extremity assessment

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,C"},"C":{"answers":"A,B,C"},"D":{"answers":"B"},"E":{"answers":"A"}}

• Recent diagnostic results: Reduced skeletal muscle electrical activity on EMG is characteristic of peripheral neuropathy. This reflects impaired nerve conduction and axonal or demyelinating damage affecting motor function. EMG findings are essential for confirming the presence of neuropathic processes.

• Report of pain: Intermittent claudication—pain in the left lower extremity with exertion—is a hallmark symptom of peripheral vascular disease. It occurs due to ischemia from arterial narrowing, typically relieved by rest. This finding aligns with vascular compromise rather than neuropathic or central causes.

• Medical history: Hypertension and prior chemotherapy increase risk for neuropathy and vascular disease. Family history of stroke and past smoking elevate the risk for TIA. Multiple chronic conditions contribute to overlapping vascular and neurologic risk factors.

• HEENT findings: Episodes of transient blurred vision suggest temporary cerebral ischemia, consistent with a TIA. Symptoms resolve quickly (less than 5 minutes in this case) and indicate impaired blood flow to the visual cortex or ocular arteries.

• Right lower extremity assessment: Footdrop indicates motor weakness caused by peripheral nerve injury, often from neuropathy. EMG confirmation of reduced electrical activity supports a neuropathic etiology for this deficit.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Start the examination with routine immunizations: Beginning with invasive procedures can increase fear and resistance in toddlers. It is best to build trust and complete nonthreatening parts of the exam first.

B. Allow the toddler to handle the equipment: Allowing the toddler to explore and handle examination tools helps reduce anxiety, promotes cooperation, and familiarizes them with unfamiliar objects. This approach aligns with developmental needs and supports a smoother assessment.

C. Thoroughly explain each procedure to the toddler: Toddlers have limited comprehension and cannot fully understand complex explanations. Simple, concrete explanations or demonstrations are more effective than detailed verbal descriptions.

D. Completely undress the toddler: Toddlers may become fearful or uncooperative if fully undressed at the start. It is safer to undress only the body part being examined to maintain comfort and security.

A. Avoid attempting to distract the client away from the hallucination. B. Encourage group activities. C. Provide low lighting in the client's room. D. Use touch to convey acceptance.

Correct Answer is C

Explanation

A. Avoid attempting to distract the client away from the hallucination: While it is important not to reinforce hallucinations, gentle redirection or distraction can help the client focus on reality and reduce distress. Avoiding all attempts at distraction may increase anxiety or withdrawal.

B. Encourage group activities: Clients actively experiencing hallucinations may have difficulty concentrating or interacting safely in a group setting. Encouraging participation at this time could increase agitation or confusion. Individualized, low-stimulation interventions are preferable.

C. Provide low lighting in the client's room: Low, soft lighting reduces environmental stimuli that can exacerbate hallucinations or agitation. Creating a calm, quiet environment supports reality orientation and helps the client manage sensory overload.

D. Use touch to convey acceptance: Physical touch may startle, confuse, or distress a client experiencing hallucinations. Safety and personal boundaries should be maintained, and touch should generally be avoided unless the client initiates or clearly consents.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who has schizophrenia and is actively hallucinating. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client in an emergency department (ED). Which of the following laboratory findings should the nurse report to the provider? Select all that apply.

A nurse is reinforcing teaching with a client who will collect stool specimens at home for fecal occult blood testing. Which of the following foods should the nurse instruct the client to avoid for 3 days before the test?

A nurse is conducting hourly rounds and finds a client lying on the floor in the bathroom. Which of the following actions should the nurse take first?

A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?

A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation?

A nurse is assisting with the care of a client in a PACU. Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for dropdowndue todropdown.