When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

Ask the client if he knows the year he married his wife.

Determine if client can recall what he ate for breakfast.

Instruct the client to follow a three-step task.

Tell the client to repeat a series of unrelated numbers.

Answer and Explanation

The Correct Answer is B

A) Ask the client if he knows the year he married his wife:
While this question may assess long-term memory, it relies on specific episodic memory of a past event. Assessing recent memory loss typically involves evaluating the ability to recall recent events or information.

B) Determine if the client can recall what he ate for breakfast:
Assessing the client's ability to recall recent events, such as what he ate for breakfast, can provide valuable information about recent memory function. This assessment is relevant to the family's concerns about recent memory loss.

C) Instruct the client to follow a three-step task:
Assessing the client's ability to follow a three-step task evaluates executive function and working memory but may not directly assess recent memory loss, which is the family's concern.

D) Tell the client to repeat a series of unrelated numbers:
Assessing the client's ability to repeat a series of unrelated numbers tests short-term memory but does not specifically address recent memory loss or the family's concerns about it.

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Correct Answer is C

Explanation

A) Inspection of head and neck is observed in a straight alignment without lateral curves:
This finding describes the normal alignment of the head and neck without lateral curves, indicating proper cervical spine alignment. While it provides information about cervical alignment, it does not directly suggest lifestyle habits that could contribute to neck stiffness and discomfort.

B) Evaluation of cranial nerve XI reveals flexion is maintained against full resistance:
Assessing cranial nerve XI (accessory nerve) involves testing the strength of the trapezius and sternocleidomastoid muscles. While weakness in these muscles may indicate pathology affecting the nerve, it does not specifically relate to lifestyle habits contributing to neck stiffness and discomfort.

C) Observation of cervical range of motion reveals flexion and extension is 25 degrees:
Limited cervical range of motion, such as the restricted flexion and extension described, may suggest musculoskeletal issues or lifestyle habits contributing to neck stiffness and discomfort. Further inquiry into the client's lifestyle habits, such as occupational activities, posture, and exercise habits, would be warranted to identify potential factors contributing to limited cervical range of motion.

D) Palpation of the spinous processes and surrounding muscles are non-tender:
Non-tender palpation of the spinous processes and surrounding muscles suggests the absence of acute musculoskeletal issues or inflammation in the cervical spine region. While it rules out tenderness on palpation, it does not provide specific information about lifestyle habits that could contribute to neck stiffness and discomfort.

A. Intranasal edema and swelling of turbinates. B. Eye tearing and thick yellow nasal drainage. C. Purulent secretions from eyes and nares. D. Snoring and bilateral, pale gray nodules.

Correct Answer is A

Explanation

A) Intranasal edema and swelling of turbinates:
Allergic rhinitis is characterized by inflammation of the nasal mucosa in response to allergen exposure. This inflammation leads to symptoms such as nasal congestion, sneezing, and rhinorrhea. Intranasal edema and swelling of the turbinates are common findings in allergic rhinitis due to the body's immune response to allergens.

B) Eye tearing and thick yellow nasal drainage:
Eye tearing and thick yellow nasal drainage are more indicative of a bacterial infection rather than allergic rhinitis. In allergic rhinitis, nasal discharge is typically clear and watery.

C) Purulent secretions from eyes and nares:
Purulent secretions from the eyes and nares suggest a bacterial infection rather than allergic rhinitis. Allergic rhinitis typically presents with clear nasal discharge, while purulent secretions are more commonly associated with bacterial sinusitis or conjunctivitis.

D) Snoring and bilateral, pale gray nodules:
Snoring and bilateral, pale gray nodules are not characteristic findings of allergic rhinitis. Snoring may be associated with nasal congestion, but pale gray nodules are not typically observed in allergic rhinitis. These findings may indicate other nasal or upper airway conditions such as nasal polyps or adenoid hypertrophy.

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When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is C

Explanation

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Correct Answer is A

Explanation

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

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?

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health? Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

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?

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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?