The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Blood is returning from the client's toe more slowly than normal.

There is a disruption in osmotic pressure in the client's extremities.

There is a blockage or infection in the client's lymphatic system.

The client's toe is receiving an inadequate supply of blood.

Answer and Explanation

The Correct Answer is D

Choice A reason: Slow venous return causes edema, not deep, painful wounds. This venous issue lacks the arterial insufficiency link to tissue necrosis, misaligning with the circular ulcer’s ischemic profile, which requires oxygen delivery, not just drainage, here fully.

Choice B reason: Osmotic pressure disruption affects fluid balance, not localized wounds. This systemic issue doesn’t explain a toe ulcer’s depth and pain, missing the vascular supply deficit driving tissue breakdown in this specific extremity finding entirely and clearly.

Choice C reason: Lymphatic blockage or infection causes swelling or lymphangitis, not deep, circular wounds. This lacks the ischemic etiology of toe ulcers, which stem from arterial insufficiency, not lymphatic dysfunction, distinguishing it from the observed pathology here fully.

Choice D reason: Inadequate arterial blood supply, as in peripheral artery disease, causes deep, painful toe ulcers due to tissue ischemia. Poor oxygen delivery leads to necrosis, matching the wound’s characteristics, making this the most likely etiology accurately and precisely.

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Correct Answer is C

Explanation

Choice A reason: Heel-to-shin tests cerebellar coordination, not balance like Romberg’s. It assesses motor precision, not proprioception or vestibular function, which Romberg’s targets by checking sway with eyes closed, making this technique irrelevant to the intended assessment here.

Choice B reason: Walking on heels and toes evaluates motor strength and coordination, not stationary balance. Romberg’s tests proprioceptive stability, not gait, missing the core focus on vestibular and sensory integration critical to this neurological balance assessment fully.

Choice C reason: Romberg’s test assesses balance by having the client stand, feet together, eyes open then closed for 20 seconds. Sway with eyes closed indicates proprioceptive or vestibular issues, making this the precise, standard technique for this evaluation accurately.

Choice D reason: Finger-to-thumb tests fine motor skills and coordination, not balance. Romberg’s focuses on postural stability via sensory input, not hand dexterity, rendering this action unrelated to assessing the client’s equilibrium as intended in this context completely.

A. VIII B. XII C. VI D. III

Correct Answer is B

Explanation

Choice A reason: Cranial nerve VIII (vestibulocochlear) governs hearing and balance, not tongue strength. A deficit here causes vertigo or deafness, not motor weakness in the tongue, making it unrelated to the observed decrease in muscle power during examination.
Choice B reason: Cranial nerve XII (hypoglossal) controls tongue movement and strength. Weakness here, as noted, suggests nerve damage, like in stroke or ALS, impairing the tongue’s ability to push against resistance, directly explaining the finding accurately.
Choice C reason: Cranial nerve VI (abducens) moves the eye laterally, not the tongue. A problem here causes diplopia, not tongue weakness, disconnecting it from the motor function loss observed in the client’s oral examination entirely here.
Choice D reason: Cranial nerve III (oculomotor) controls eye movement and pupil response, not tongue strength. Its dysfunction leads to ptosis or eye deviation, irrelevant to the tongue’s motor impairment noted in this neurological assessment fully.

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The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the Romberg's test on a patient. Which is the correct technique for conducting this?

Correct Answer is C

Explanation

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

Correct Answer is B

Explanation

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