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Exhibits

Which assessment(s) should the nurse conduct? Select all that apply.

Muscle tone

Level of consciousness

Cranial nerves

Brudzinski reflexes

Pupil size

Glasgow coma scale

Romberg's test

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Muscle tone: Assessing muscle tone is important to evaluate for motor deficits or neurological impairments that may have contributed to the fall or been caused by a cerebrovascular event.

B. Level of consciousness: The client’s inability to recall the events leading to the fall requires an assessment of mental status and level of consciousness to identify potential cognitive or neurological issues.

C. Cranial nerves: A cranial nerve assessment can detect focal neurological deficits indicative of stroke or other neurological conditions.

D. Brudzinski reflexes: This reflex is assessed for meningitis and would not be relevant in this scenario as the client does not exhibit symptoms such as fever, nuchal rigidity, or photophobia.

E. Pupil size: Changes in pupil size and reactivity may indicate increased intracranial pressure or other neurological changes.

F. Glasgow Coma Scale (GCS): This scale is crucial for assessing the client’s neurological status and level of consciousness, especially given the fall and dizziness.

G. Romberg's test: This test evaluates balance and proprioception, but it is less appropriate in the acute setting when the priority is to assess for neurological deficits related to the fall or potential cerebrovascular event.

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Correct Answer is B

Explanation

A. Sudden onset of severe anxiety, fear, and concern: These symptoms are not indicative of appendicitis.

B. Periumbilical pain localizing to the right lower quadrant: This is a classic sign of appendicitis due to inflammation irritating surrounding tissues.

C. Anorexia progressing to nausea, vomiting, and fever: While common in appendicitis, these findings are non-specific.

D. Diffuse abdominal pain with elevated neutrophil count: Appendicitis pain typically localizes rather than remaining diffuse.

A. Tympany. B. Aneurysm. C. Hernia. D. Appendicitis.

Correct Answer is B

Explanation

A. Tympany refers to a hollow, drum-like sound heard on percussion, indicating air in the abdomen but not a pulsating mass.

B. A pulsating, centrally localized abdominal distention is most concerning for an abdominal aortic aneurysm (AAA), which can be life-threatening if it ruptures.

C. Hernia typically presents as a bulging mass but does not usually cause pulsation.

D. Appendicitis usually causes localized pain in the right lower quadrant, not pulsating distention.

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Exhibits Which assessment(s) should the nurse conduct? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Correct Answer is B

Explanation

When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

Correct Answer is B

Explanation

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Exhibits

Which assessment(s) should the nurse conduct? Select all that apply.