The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

Brachial

Ulnar

Femoral

Radial

Answer and Explanation

The Correct Answer is B

Choice A reason: Brachial pulse, in the upper arm, is strong and palpable in healthy adults, used for blood pressure cuffs. Its deep location ensures consistent detection, unlike weaker pulses, making it reliably felt across most individuals without vascular issues here.

Choice B reason: Ulnar pulse, near the wrist’s pinky side, is often faint or not palpable in many healthy people due to its depth and smaller artery size. This variability distinguishes it as less detectable compared to other major pulses consistently.

Choice C reason: Femoral pulse, in the groin, is robust and palpable in healthy adults, reflecting large artery flow to the legs. Its prominence ensures detection, unlike the ulnar, making it a standard check not commonly absent in normal assessments fully.

Choice D reason: Radial pulse, at the wrist’s thumb side, is easily palpable in healthy clients, a key vital sign check. Its superficial location ensures consistent detection, contrasting with the ulnar’s frequent elusiveness in normal peripheral exams entirely here.

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Correct Answer is C

Explanation

Choice A reason: Ischemic stroke causes focal deficits like weakness, not neck flexion-induced leg pain. This vascular event lacks meningeal irritation signs, misaligning with the positive Brudzinski’s sign of knee bending and neck pain in this assessment fully here.
Choice B reason: Trigeminal neuralgia triggers facial pain, not leg or neck pain with flexion. This cranial nerve V issue doesn’t involve meningeal inflammation, excluding it from the systemic response seen in this neck maneuver entirely and accurately here.
Choice C reason: Meningitis causes meningeal irritation; neck flexion (Brudzinski’s sign) elicits leg pain and knee bending. Neck pain aligns with inflammation, making this the likely diagnosis for the client’s response to this specific neurological test comprehensively here.
Choice D reason: Bell’s palsy affects cranial nerve VII, causing facial paralysis, not leg or neck pain. This peripheral nerve issue lacks the meningeal signs triggered by neck flexion, ruling it out as the cause in this scenario fully here.

A. Use an ophthalmoscope to view the optic disc and retina. B. Have the client move his eyes in the 6 cardinal fields of gaze. C. Use a tuning fork to see if the client can sense vibration on the closed eyelids bilaterally. D. Have the client turn his head to track the nurse's hand movement as it makes a 360 curve around the client's head.

Correct Answer is B

Explanation

Choice A reason: Ophthalmoscopy checks cranial nerve II (optic), not III, IV, or VI. It visualizes the retina, missing the eye movement control these nerves govern, making it irrelevant to their motor function assessment entirely here fully.
Choice B reason: The 6 cardinal fields test cranial nerves III (eye movement, pupil), IV (superior oblique), and VI (lateral rectus). This single technique evaluates all three by tracking coordinated eye motion, making it the most efficient method accurately here.
Choice C reason: Vibration on eyelids tests sensation, possibly cranial nerve V, not III, IV, or VI. These nerves control eye movement, not sensory input, excluding this from assessing their motor roles in this neurological exam fully here.
Choice D reason: Head turning with hand tracking involves neck muscles and possibly cranial nerve XI, not just III, IV, VI. This dilutes focus on eye-specific movements, making it less precise for these cranial nerves’ assessment entirely here.

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The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has placed her hands behind the client's head and flexed his neck forward as far as he can tolerate. During the test the client experiences leg pain and bends his knees. In addition, he complains of neck pain. This assessment finding is suggestive of what health problem?

Correct Answer is C

Explanation

The nurse is assessing cranial nerves 3, 4 and 6 (oculomotor, trochlear and abducens). Which technique might the nurse use to assess all three in one technique?

Correct Answer is B

Explanation

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