The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Battle sign.

Chvostek's sign.

Romberg sign.

Babinski sign.

Answer and Explanation

The Correct Answer is C

A.   Battle sign refers to bruising behind the ears and is a sign of head trauma, not intoxication.
B.   Chvostek's sign is related to hypocalcemia, not intoxication.
C.   Romberg sign assesses for balance issues when standing with eyes closed and is commonly positive in clients with neurological impairment, including intoxication.
D.   Babinski sign is related to neurological disorders and would not be directly associated with intoxication.

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Correct Answer is D

Explanation

A. Absent deep tendon reflexes are not typically associated with nailbed clubbing. While reflexes may be diminished in some conditions, they are not commonly related to the pathophysiology behind clubbing.
B. A capillary refill time of less than 3 seconds is a normal finding and does not align with clubbing, which often indicates chronic hypoxia or systemic conditions such as heart or lung disease.
C. Peripheral dependent edema refers to swelling in the lower extremities, which can be associated with circulatory problems, but it is not directly linked to nailbed clubbing. Edema is more common in conditions like heart failure or kidney disease.
D. A low oxygen saturation of 85% is consistent with conditions that cause chronic hypoxia, such as chronic lung disease or congenital heart disease. Chronic low oxygen levels can lead to nailbed clubbing as a compensatory response to inadequate oxygenation.

A. Hematocrit changes from 36% to 32%. B. Hemoglobin A1C changes from 10% to 8%. C. Prothrombin time (PT) changes from 12 seconds to 18 seconds. D. Guaiac test changes from positive to negative.

Correct Answer is A

Explanation

A. A decrease in hematocrit from 36% to 32% suggests ongoing blood loss and that the client’s GI bleeding has not yet resolved. Hematocrit is a key indicator of the client’s blood volume and oxygen- carrying capacity.
B. Hemoglobin A1C reflects long-term blood sugar control, not current blood loss. A change in A1C is not indicative of GI bleeding resolution.
C. An increase in prothrombin time (PT) from 12 to 18 seconds indicates clotting abnormalities, which may occur with liver dysfunction or anticoagulant therapy, but it doesn't directly relate to GI bleeding resolution.
D. A positive to negative change in the guaiac test (fecal occult blood test) would indicate that the blood in the stool is no longer present, suggesting resolution of bleeding, which doesn’t match the question’s context.

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The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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