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 C

Explanation

A. Estimating the degree of flexion and extension in each joint primarily assesses the range of motion, not specifically muscle strength.
B. Measuring the degree of force required to overcome joint flexion or extension may assess resistance but doesn't directly evaluate muscle strength.
C. Applying an opposing force when the individual puts a joint in flexion or extension is an accurate method to assess muscle strength, as it evaluates the force the muscle can generate against resistance.
D. Observing muscles for contraction while lifting a heavy object evaluates muscle usage but doesn’t offer a standardized way to assess muscle strength.

A. Heart failure B. Excess fluid retention C. Excess fluid consumption D. Pulmonary embolism

Correct Answer is A

Explanation

A. Heart failure can lead to fluid accumulation in the legs due to the heart's inability to effectively pump blood, causing increased pressure in the veins.
B. Excess fluid retention or consumption might cause edema, but heart failure specifically impacts the heart's pumping function.
C. Excess fluid consumption might contribute to temporary edema, but severe bilateral lower extremity edema is more likely due to a systemic issue like heart failure.
D. While a pulmonary embolism can lead to edema in the legs, it typically presents with sudden onset and might not present with bilateral edema from feet to knees.

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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

The nurse is preparing to complete a muscle strength assessment on a client. Which of the following assessment techniques should the nurse utilize?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?

During a community screening event for bone density, an elderly client asked the nurse why she is an inch shorter in height. Which of the following responses by the nurse is correct?

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?

The nurse is describing how to perform a testicular self-examination to a client. Which of the following should be the appropriate statement by the nurse?

The nurse is assessing the male genital organ. The nurse recognizes that which of the following is an accessory glandular structure for the male genital organs?

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?