The nurse is performing a neurological assessment on a client with a history of Diabetes.

When testing the ability to feel the vibrations of a tuning fork, the nurse notices that the client is unable to feel vibrations on the great toe or ankle bilaterally, but is able to feel vibrations on both patellae. What should the nurse suspect from these assessments?

Hyperalgesia

Peripheral neuropathy

Hyperparalysis

Lesion of the sensory cortex

Answer and Explanation

The Correct Answer is B

A.   Hyperalgesia refers to increased sensitivity to pain stimuli, not specifically related to the inability to feel vibrations.
B.   Peripheral neuropathy, a common complication of diabetes, often leads to sensory deficits, especially in distal extremities like the toes and feet.
C.   Hyperparalysis is not a recognized term in neurology.
D.   A lesion of the sensory cortex would likely present with broader sensory deficits rather than a specific loss of vibration sensation in the distal lower extremities.

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Correct Answer is A

Explanation

A. Interphalangeal joints are the joints between the phalanges, since the client is unable to remove a ring, the most likely affected joint is the interphalangeal joint.
B. The Tibiotalar joint is the ankle joint.
C. Metacarpophalangeal joint refers to the joint between the metacarpal bones in the upper limbs and the phalanges.
D. Tarsometatarsal joints are the joints between the tarsal bones of the foot and metatarsal bones.

A. 1 minute in the center of the abdomen. B. 10 minutes in each quadrant. C. 1 minute in each quadrant. D. 5 minutes in each quadrant. E. None F. None

Correct Answer is D

Explanation

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's fingers. The client complains of a swollen, painful knuckle and not being able to remove a ring from that finger. The nurse recognizes which of the following is the correct term for the affected joint.

Correct Answer is A

Explanation

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is D

Explanation

A client reports pain in the left wrist after falling while playing basketball. After assessing the wrist, which of the following assessment finding would make the nurse suspect a fracture?

The nurse is performing a scrotal assessment on a male client. Which of the following findings of the scrotum should the nurse recognize as abnormal?

A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:

The nurse teaches a client that there are shock absorbers in the back to cushion the spine and to help it move. The client understands that which of the following is another name for shock absorbers:

A 60-year-old man has been told that he has benign prostatic hypertrophy (BPH). He expresses that his friend just died from prostate cancer and that he is concerned about dying from cancer. Which of the following is an appropriate response by the nurse?

The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

A male client with possible fertility problems asks the nurse where sperm is produced. Which answer should the nurse give the client?

A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?