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Patient Data

Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.

Brudzinski reflexes

Muscle tone

Romberg's test

Level of consciousness

Pupil size

Cranial nerves

Glasgow coma scale

Answer and Explanation

Correct Answer : B,C,D,E,F,G

A.   Brudzinski reflexes test is primarily used to assess for meningeal irritation, which is not directly related to stroke.
B.   Muscle tone assessments help to identify abnormalities in motor function, which could indicate neurological damage. Given the patient’s history and the recent fall, muscle tone should be checked for any signs of weakness or spasticity.
C.   This test evaluates the client’s balance and proprioception. It is a quick way to check for potential issues with the nervous system, such as ataxia or other motor impairments, which could be present in a client with a stroke.
D.   Assessing the level of consciousness is critical in a neurological assessment to ensure that the client is oriented and alert, which is especially important after a fall or stroke-like symptoms.
E.   Pupillary response is an essential part of a neurological exam. Checking the size and reactivity of the pupils helps to assess brainstem function and overall neurological health.
F.   Cranial nerve function should be assessed to evaluate for signs of neurological deficits. In stroke patients, cranial nerve impairments can provide important diagnostic information.
G.   The Glasgow Coma Scale (GCS) is a standard tool for assessing the level of consciousness and neurological status. It can provide valuable insights into the severity of a neurological condition, especially in post-fall or post-stroke patients.

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Correct Answer is D

Explanation

A. A hematoma refers to a collection of blood outside of blood vessels, typically resulting in a bruise or swelling. The description of round, flat, pinpoint red spots does not suggest this type of injury.
B. Vesicles are small fluid-filled blisters, which do not match the description of the pinpoint red spots. Vesicles would be more elevated and contain fluid.
C. Ecchymosis refers to a bruise, or large, irregular areas of discoloration caused by blood leaking into the tissues. The description of pinpoint red spots suggests petechiae, not ecchymosis.
D. Petechiae are small, round, flat, pinpoint red or purple spots that occur when small blood vessels (capillaries) break under the skin. This is the most appropriate description for the observed finding, particularly in the context of trauma from intimate partner violence.

A. A lifestyle with minimal physical activity. B. Works more than 12 hours in a day. C. History of type 2 diabetes mellitus. D. A phosphodiesterase inhibitor on the medication list.

Correct Answer is C

Explanation

A. A lifestyle with minimal physical activity may contribute to general health issues, but it is not as directly linked to erectile dysfunction as conditions like diabetes.
B. Working long hours can cause stress or fatigue, which may indirectly affect sexual function, but it is not a direct cause of erectile dysfunction.
C. Type 2 diabetes mellitus is a well-known risk factor for erectile dysfunction due to its impact on blood flow and nerve function, both of which are essential for normal erectile function.
D. A phosphodiesterase inhibitor is often used to treat erectile dysfunction, but its presence on the medication list is more likely a treatment rather than a cause.

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Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is D

Explanation

When the nurse is obtaining health history during an annual physical examination, the client reports having difficulty with erections for the past 8 months. Which information in the client's history should the nurse consider as a potential reason for erectile dysfunction?

Correct Answer is C

Explanation

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?

Patient Data

Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.