During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:

May indicate disease of the cerebellum or brainstem.

is a sign that the patient is nervous about the examination

Indicates a visual problem, and a referral to an ophthalmologist is indicated.

is a normal occurrence

Answer and Explanation

The Correct Answer is A

A.   Severe nystagmus is often associated with neurological disorders, particularly those affecting the cerebellum or brainstem.
B.   is a sign that the patient is nervous about the examination. Nervousness typically doesn’t cause severe, persistent nystagmus.
C.   Indicates a visual problem, and a referral to an ophthalmologist is indicated. While nystagmus affects vision, it is usually neurologically based, requiring a neurological assessment rather than a referral to an ophthalmologist.
D.   Nystagmus is not typically normal, especially when it is severe and persistent. It warrants further investigation.

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Correct Answer is A

Explanation

A. Palpation should be done after auscultation to avoid altering the bowel sounds. Palpation can cause changes in the sounds, making it difficult to assess accurately.
B. It is advisable to auscultate bowel sounds when the patient is not actively eating, so this action is appropriate.
C. This is the correct duration for assessing bowel sounds. Auscultating for 3-5 minutes is within the standard practice.
D. If the client has an NG tube, clamping it before auscultation is appropriate as it prevents additional noises or interference from the tube.

A. Pulse 68 bpm B. 7 x 4 cm scar on the left lower abdomen. C. Blood pressure 148/92 D. History of allergies E. Last menstrual period F. Shortness of breath G. Pain 8/10 H. Brawny edema in lower extremities. I. Temperature 101 SF J. Use of medications at home

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"B"},"I":{"answers":"B"},"J":{"answers":"A"}}

Explanation

Subjective data are based on what the patient reports. These include personal history and symptoms (e.g., allergies, menstrual period, pain level, and medication use).

Objective data are measurable facts that are observed or measured by the nurse, such as vital signs, physical findings (e.g., scars, edema), and lab results (e.g., temperature, blood pressure).

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During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Correct Answer is A

Explanation

​​​​​​​The nurse is performing a physical assessment on a newly admitted patient. Select subjective or objective for the findings below.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"B"},"I":{"answers":"B"},"J":{"answers":"A"}}

Explanation

Which assessment finding(s) for a client with hypothyroidism should the nurse document as abnormal? Select all that apply.

While conducting a cultural health assessment a nurse should include which of the following?

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

The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

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?

The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take?

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

A newly admitted patient is having generalized anxiety, headache with pain level 4/10, and shortness of breath at rest. How should the nurse prioritize these problems?