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A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next?
- A. Touch the pin on the same area of the left hand.
- B. Contact the provider with the assessment results.
- C. Document the findings and end the assessment.
- D. Continue the assessment on the client's feet.
Correct Answer: A
Rationale: After confirming normal pain sensation on the right hand, the nurse should assess the left hand to ensure bilateral symmetry before moving to other areas like the feet. The finding is normal and does not require immediate reporting.
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A nurse assesses a client's recent memory. Which client statement confirms that the client's recent memory is intact?
- A. A young girl wrapped in a shroud fell asleep on a bed of clouds.
- B. I was born on April 3, 1967, in Johnstown Community Hospital.
- C. Apple, chair, and pencil are the words you just stated.
- D. I ate oatmeal with wheat toast and orange juice for breakfast.
Correct Answer: D
Rationale: Asking clients about recent events that can be verified, such as what they ate for breakfast, assesses recent memory. The other options assess different cognitive functions: making up a rhyme tests higher cognition, recalling birth details tests remote memory, and repeating words tests immediate memory.
A nurse delegates care for a client with cranial nerve II impairment to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care?
- A. Tell the client where food items are on the meal tray.
- B. Assist the client with ambulation to the bathroom.
- C. Check the client's skin for pressure ulcers daily.
- D. Provide the client with a whiteboard to communicate.
Correct Answer: A
Rationale: Cranial nerve II (optic nerve) impairment causes vision loss, so describing food placement on the tray helps the client eat independently. The other options address unrelated issues like mobility or communication.
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition is most likely?
- A. Difficulty with proprioception
- B. Peripheral motor disorder
- C. Impaired cerebral function
- D. Positive pronator drift
Correct Answer: A
Rationale: A positive Romberg's sign with eyes closed but not with eyes open indicates difficulty with proprioception, as the client relies on vision to compensate for impaired position sense. The other options do not specifically describe this clinical finding.
A nurse assesses a client and notes the client's position as indicated in the illustration below: How should the nurse document this finding?
- A. Decorticate posturing
- B. Decerebrate posturing
- C. Flaccid posturing
- D. Spinal cord degeneration
Correct Answer: A
Rationale: Decorticate posturing indicates corticospinal pathway interruption, a serious finding requiring immediate documentation and reporting. The other options do not accurately describe this abnormal posture.
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider?
- A. Shingles on the client's back
- B. Client is claustrophobic
- C. Absence of intravenous access
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Shingles at the puncture site increases infection risk, requiring the nurse to notify the provider. Claustrophobia, lack of IV access, or dyspnea can be managed without canceling the procedure.