The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:

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:

A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient.

A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

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

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

A nurse needs to obtain anthropometric measures of an 80-year-old client. Which of the following statements is true regarding this situation?

Renee is a 43-year-old female who presents to her gynecology office to follow up on a breast lump she discovered while performing a self-exam two days ago. Renee explains she has a family history of breast cancer. Her mother was diagnosed with stage Ill breast cancer at 40 years and passed away 5 years later. Renee's sister tested BRACA and elected to undergo a prophylactic double mastectomy Renee underwent BRACA testing and was found to be but she elected not to undergo the surgery. Considering the strong family history, Renee presents annually for mammograms and performs self-breast exams once a month. Two days ago, while performing her monthly exam in the shower. Renee felt a firm, non-tender lump in the right breast located to the right of the nipple. She immediately called to schedule an appointment for consultation.

Renee denies any associated symptoms including fatigue, changes to the skin of the breast pain, discharge from the nipples, or sore lymph nodes She describes herself as healthy and has no.
The nurse prepares to perform a breast exam on Renee to evaluate the palpable mass. When documenting pertinent objective findings related to the breast mass characteristics, the nurse includes information on (Select all that apply)

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

During a cardiovascular assessment of an 80-year-old adult, a nurse should consider which of the following as expected findings?