Nokea
The nurse is observing a student perform a physical assessment. It will demonstrate appropriate technique if the student assesses for stereognosis by instructing the client to
- A. Close their eyes, place an object in their hand, and ask them to identify it.
- B. Close their eyes with feet together, arms at the sides, and observe for loss of balance.
- C. Walk on their heels and then on their tiptoes for at least ten feet.
- D. Touch the tip of their nose with the index finger and return the arm to an extended position.
Correct Answer: A
Rationale: Stereognosis is tested by placing an object in the client’s hand with eyes closed to assess tactile recognition. Other options test balance, gait, or coordination.
You may also like to solve these questions
The nurse is caring for a client who reports abdominal pain. When performing an abdominal assessment, the nurse should
- A. Auscultate for bowel sounds after inspecting the abdomen.
- B. Palpate the area where the client identifies pain prior to palpating other areas.
- C. Palpate to detect fluid, air, and fluid-filled or solid masses.
- D. Percuss for masses, tenderness, organ enlargement, and ascites.
Correct Answer: A
Rationale: Abdominal assessment follows the order: inspect, auscultate, percuss, palpate. Auscultation after inspection prevents altering bowel sounds. Palpating painful areas first or focusing only on palpation/percussion is incorrect.
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.
The nurse is teaching a client how to ambulate using a walker. The nurse should
- A. Have the client stand on the side of the walker to have them properly fitted.
- B. Position the top of the walker so it lines up with the client's wrist crease.
- C. Ensure the client's feet are close together while holding onto the walker handgrips.
- D. Instruct the client to lean forward over the walker so they do not lose balance.
- G. None
Correct Answer: B
Rationale: The walker’s top aligns with the wrist crease for proper height. Standing on the side, close feet, or leaning forward are unsafe or incorrect for fitting or use.
The nurse performs palpation and percussion during a head-to-toe assessment. Over which organ would the nurse expect to hear tympany when percussed?
- A. Stomach
- B. Liver
- C. Normal lung tissue
- D. Tympany is an abnormal finding
Correct Answer: A
Rationale: Tympany, a hollow sound, is expected over the stomach due to air in the gastric bubble. Liver produces dullness, lungs produce resonance, and tympany is normal in certain areas.
The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.