The nurse is taking a health history from a client. The client tells the nurse that. "It feels like the room is spinning." How should the nurse document this finding?

Vertigo

Seizure activity

Dizziness

Syncope

Answer and Explanation

The Correct Answer is A

A.   Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B.   Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C.   Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D.   Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.

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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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The nurse is taking a health history from a client. The client tells the nurse that. "It feels like the room is spinning." How should the nurse document this finding?

Nursing Test Bank

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

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