As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon?

Mental

Physical

Spiritual

Interpersonal

Answer and Explanation

The Correct Answer is A

A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.

B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.

C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.

D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.

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Correct Answer is A

Explanation

A. T wave: The T wave represents ventricular repolarization (relaxation), indicating the end of the ventricular contraction phase.

B. QRS complex: The QRS complex represents ventricular depolarization (contraction), not repolarization.

C. P wave: The P wave represents atrial depolarization, not ventricular repolarization.

D. ST segment: The ST segment represents the time between ventricular depolarization and repolarization, but it is not the waveform indicating repolarization itself.

A. Mental status examination B. Mouth and throat C. Head and face D. Ears E. Hematocrit 47% (37% to 47%)

Correct Answer is D

Explanation

A. Mental status examination: This part of the assessment evaluates cognitive functions, not sensory functions related to cranial nerve VIII.

B. Mouth and throat: This area assesses cranial nerves related to swallowing and speech but not the sensory function of cranial nerve VIII.

C. Head and face: This includes assessing cranial nerves related to facial sensation and movement but not the auditory function of cranial nerve VIII.

D. Ears: Cranial nerve VIII, the vestibulocochlear nerve, is responsible for hearing and balance, so assessing sensory function related to this nerve occurs during the examination of the ears.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

Correct Answer is A

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

Correct Answer is D

Explanation

Which general survey question focuses on the common "fifth vital sign"?

Which type of assessment includes a health history and physical assessment?

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

A patient is unable to taste in the 2/3 anterior of his tongue. Which cranial nerve is affected?

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? (Select all that apply.)