The nurse is performing an assessment and finds that the client has nontarry and black stool. Which of the following subjective data should the nurse document as a normal finding consistent with nontarry black stool?

client reports taking iron supplement

client has dry heaves

client reports eating red meat prior to assessment

client report loss of appetite

Answer and Explanation

The Correct Answer is A

Choice A rationale: Taking an iron supplement can lead to nontarry and black stool due to the dark color of iron.

Choice B rationale: Dry heaves are not typically associated with nontarry black stool. Choice C rationale: Eating red meat would result in reddish stool, not black. Choice D rationale: Loss of appetite is not directly related to the appearance of stool.

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Correct Answer is B

Explanation

Choice A rationale: Hyperalgesia refers to increased sensitivity to pain and is not evident in this scenario.

Choice B rationale: Inability to feel vibrations in the great toe or ankle bilaterally suggests peripheral neuropathy, which is a common complication of diabetes affecting the peripheral nerves.

Choice C rationale: Hyperparalysis is not a recognized term in the context of this assessment.

Choice D rationale: Lesion of the sensory cortex would likely have more widespread sensory deficits and wouldn't selectively affect the great toe and ankle.

A. When the client sticks out the tongue it is in the midline and without tremors or deviation B. Client follows an object with eyes without nystagmus or strabismus. C. Client demonstrates the ability to hear normal conversation D. Client moves the head and shoulders against resistance with equal strength.

Correct Answer is D

Explanation

Choice A rationale: Sticking out the tongue without tremors or deviation is related to Cranial Nerve XII (hypoglossal nerve), not Cranial Nerve XI.

Choice B rationale: Following an object with the eyes without nystagmus or strabismus is more related to visual tracking and coordination, not Cranial Nerve XI.

Choice C rationale: Hearing ability is primarily associated with Cranial Nerve VIII (vestibulocochlear nerve), not Cranial Nerve XI.

Choice D rationale: Cranial Nerve XI, also known as the accessory nerve, is responsible for the movement of the head and shoulders against resistance. If intact, the client should be able to perform this action with equal strength on both sides.

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The nurse is performing an assessment and finds that the client has nontarry and black stool. Which of the following subjective data should the nurse document as a normal finding consistent with nontarry black stool?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Correct Answer is D

Explanation

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