An adult male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter?

An adult male presents with fears that he has "lung cancer."

Describes having a body-wracking dry cough" of 6 weeks duration.

Expresses concern of "lung cancer" symptoms for last 6 weeks.

Presents with a hacking non-productive cough of 6 weeks duration.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
An adult male presents with fears that he has "lung cancer." Is appropriate. This choice accurately captures the client's expressed fear of having lung cancer. However, it lacks specificity regarding the duration of symptoms (six weeks) and the nature of the symptom (dry cough). Therefore, while it acknowledges the client's concern, it does not provide comprehensive documentation of the client's reported symptoms.
Choice B Reason:
This option accurately captures the client's primary concern, which is the persistent dry cough lasting for six weeks. It avoids assuming a diagnosis (such as lung cancer) and instead focuses on the client's reported symptom. This type of documentation allows for an objective record of the client's statement while avoiding speculation about specific diagnoses. It also provides important information that can guide further assessment and diagnostic evaluation by healthcare providers.
Choice C Reason:
This option documents the client's expressed concern about having symptoms consistent with lung cancer for the past six weeks. While it accurately reflects the client's fear, it may lead to premature assumptions about the diagnosis before a thorough assessment and diagnostic workup are conducted. It's important for documentation to focus on the client's reported symptoms rather than presumptive diagnoses to maintain objectivity and guide appropriate evaluation and management..
Choice D Reason:
Presents with a hacking non-productive cough of 6 weeks duration. This choice accurately describes the client's reported symptom of a "hacking non-productive cough" and includes the duration of the symptom (six weeks). However, it does not explicitly mention the client's expressed fear of having lung cancer, which is an important aspect of the client's presentation that should be documented. Additionally, the term "hacking" may not fully capture the severity or character of the client's reported cough, as the client described it as "body-wracking." Therefore, while it provides some relevant information, it does not fully capture the client's concerns and presentation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:
Shrug shoulders against resistance is correct because cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles. Instructing the client to shrug their shoulders against resistance tests the strength and function of the trapezius muscle, which is primarily innervated by cranial nerve XI. Therefore, this instruction directly assesses the function of the cranial nerve XI.
Choice B Reason:
Stand up slowly with eyes closed is incorrect because standing up slowly with eyes closed primarily assesses proprioception and balance, which involve multiple cranial nerves and the vestibular system. While cranial nerve XI may play a role in maintaining posture and balance, it is not the primary nerve involved in this assessment.
Choice C Reason:
Turn head from side to side is incorrect because turning the head from side to side primarily assesses the function of the sternocleidomastoid muscle, which is also innervated by cranial nerve XI. However, this action alone does not provide resistance against which the muscle can contract, making it less specific for assessing cranial nerve XI compared to the instruction to shrug the shoulders against resistance.
Choice D Reason:
Raise both arms overhead incorrect because raising both arms overhead primarily assesses motor function and strength of the upper extremities, which do not directly involve the muscles innervated by cranial nerve XI. While the trapezius muscle may be indirectly involved in shoulder movement, this action does not specifically target the function of cranial nerve XI.

A. Motor responses. B. Eye opening. C. Verbal response D. Level of alertness.

Correct Answer is D

Explanation

a. "Motor responses."Motor responses are important in assessing neurological function, but they are typically assessed after determining the client's overall level of consciousness and alertness. Motor responses are usually assessed when the client is unresponsive or has altered consciousness.

b. "Eye opening."Eye opening is part of the Glasgow Coma Scale (GCS) and is an important indicator of neurological function. However, it is generally assessed after determining the client's level of alertness.

c. "Verbal response."Verbal response is another component of the GCS, assessing how the client responds to verbal stimuli. This assessment also follows the initial determination of the client’s alertness.

d. "Level of alertness."The level of alertness is the first and most fundamental aspect to assess because it gives the nurse a baseline understanding of how aware the client is of their surroundings. This assessment sets the stage for further evaluation of motor, eye, and verbal responses. It helps determine the client's ability to interact and respond to stimuli, guiding subsequent assessments.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

Correct Answer is A

Explanation

In assessing a client's level of consciousness, what should the nurse assess first?

Correct Answer is D

Explanation

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

The primary nurse asks another nurse to assist in checking a client for an apical-radial pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding?

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?