The nurse performs a two-point discrimination test by applying two sterile needles lightly to the fingertips and moving the needle tips in ever-closing distances. A middle-aged adult client senses two points at a distance of 3 mm on the fingertips and 10 mm on the palms of the hands. Which interpretation of this finding is accurate?

Paresthesia.

Rebound reaction to the needle points.

Normal sensory finding.

Marginal decline in sensory function.

Answer and Explanation

The Correct Answer is C

A) Paresthesia: Paresthesia refers to abnormal sensations such as tingling, pricking, or numbness, typically without an external stimulus. The client's ability to discriminate two points at specific distances on the fingertips and palms does not indicate abnormal sensations or paresthesia.

B) Rebound reaction to the needle points: A rebound reaction would involve a delayed response or heightened sensitivity following the removal of a stimulus. This test does not measure rebound reactions but rather the ability to discriminate two separate points.

C) Normal sensory finding: The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. The fingertips typically have a higher density of sensory receptors and thus can discriminate smaller distances between two points, whereas the palms have fewer receptors and require a greater distance to discern two points.

D) Marginal decline in sensory function: The described ability to sense two points at these specific distances does not indicate a decline in sensory function. It aligns with normal findings for a middle-aged adult.

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Correct Answer is B

Explanation

A) Abduct each hip while the client is supine:
While assessing hip abduction can provide information about hip joint mobility, it may not be the most appropriate initial assessment for hip dysfunction. This action primarily evaluates the range of motion but may not specifically target dysfunction in the hip region.

B) Flex the hip and knee while standing:
Flexing the hip and knee while the client is standing can help assess hip function, particularly in weight-bearing positions. This action can reveal limitations in hip mobility and detect dysfunction such as pain or weakness during movement.

C) Observe balance while the client stands:
Observing balance while the client stands is important for assessing overall lower extremity function, including the hips. However, it may not specifically target dysfunction in the hip region and may provide more general information about mobility and stability.

D) Inspect gluteal folds for symmetry:
Inspecting gluteal folds for symmetry can help identify asymmetry or abnormalities in the hip region, but it may not provide direct information about hip dysfunction. This action is more focused on assessing external appearance rather than functional movement or mobility.

A. Diabetes mellitus. B. Recent candida infection. C. Iron deficiency anemia. D. Coronary heart disease.

Correct Answer is C

Explanation

A) Diabetes mellitus: While diabetes can lead to various complications affecting the nails, such as yellowing or thickening due to poor circulation and infections, it is not typically associated with brittle, concave (spoon-shaped) nails.

B) Recent candida infection: Candida infections can affect the nails, causing them to become discolored, thickened, or separated from the nail bed, but they do not typically cause the nails to become brittle and concave.

C) Iron deficiency anemia: This condition is often associated with brittle, spoon-shaped (concave) nails, known as koilonychia. Iron deficiency anemia affects the oxygen-carrying capacity of the blood, which can lead to changes in the nail beds, making them appear concave and brittle.

D) Coronary heart disease: While coronary heart disease can lead to changes in the nails due to poor circulation, it is not commonly associated with the specific finding of brittle, concave nails. Other nail changes might include clubbing or cyanosis, but not typically koilonychia.

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Naxlex Comprehensive Predictor Exams

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Correct Answer is B

Explanation

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

Correct Answer is C

Explanation

A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

When evaluating a client's rectal bleeding, which findings should the nurse document?