The nurse is assessing a client who reports an abnormal sensation of burning or tingling in extremities. Which of the following should the nurse document in the client's record?

paralysis.

hemiparesis.

paraphasia.

paresthesia.

Answer and Explanation

The Correct Answer is D

A.   Paralysis refers to the loss of muscle function in part of your body.
B.   Hemiparesis is weakness on one side of the body.
C.   Paraphasia is a language disorder where words get jumbled and sentences don't make sense.
D.   Paresthesia is an abnormal sensation like tingling, burning, or numbness in the extremities often associated with nerve-related issues.

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Correct Answer is D

Explanation

A. Listening to speech primarily assesses cranial nerves related to speech and articulation, not cranial nerve II.
B. Identifying scented aromas assesses the olfactory nerve.
C. Clenching teeth primarily assess cranial nerve V (trigeminal nerve).
D. Cranial nerve II is the optic nerve responsible for vision. Testing visual acuity using a Snellen chart assesses this nerve's function.

A. Recognizes this dullness as indicative of an enlarged liver, and refers the client to a provider B. Document the presence of hepatomegaly C. Ask additional health history questions regarding alcohol intake D. Recognizes this finding as normal, and proceed with the examination

Correct Answer is A

Explanation

A. Dullness above the right costal margin could indicate an enlarged liver. Referring the client to a healthcare provider is crucial for further evaluation and diagnosis.
B. Documenting hepatomegaly without further investigation or confirmation by a healthcare provider could be premature.
C. While alcohol intake can be a factor in liver conditions, additional history alone may not confirm the cause of the dullness. Direct evaluation by a healthcare provider is necessary.
D. Finding an area of dullness above the right costal margin, particularly of such magnitude, should prompt further investigation rather than being considered normal.

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The nurse is assessing a client who reports an abnormal sensation of burning or tingling in extremities. Which of the following should the nurse document in the client's record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Correct Answer is D

Explanation

The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?

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