Health Assessment 4

What should the nurse assess to test the function of the occipital lobe?

Ability to read

Francis is a middle-aged man who noted right sided lower abdominal pain after straining with yardwork. Which of the following findings would make a hernia a more likely diagnosis?

Absence of symmetry of the inguinal areas with straining

Where is the corona of the penis found?

At the base of the glans

A nurse examining a client's external genitalia notices that his scrotum and testes draw up and he shivers. This phenomenon is known as which of the following?

Cremasteric reflex

A client is concerned about his risk for developing testicular cancer. Which of the following should the nurse mention as a risk factor for this type of cancer?

Cryptorchidism

As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease?

Decreased proprioception

The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what?

Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over a time, amnesia is a loss of memory and hypoxia may be a cause of delirium.

A 7-year-old child comes to the clinic with her mother, who states that her daughter is doing poorly in school because she has some kind of "ADD" (attention deficit disorder). The nurse asks the mother what makes her think the child has ADD. The mother says that both at home and at school her daughter just zones out for several seconds and licks her lips. She states it happens at least four to six times an hour. She says this has been happening for about 1 year. After several seconds of lip licking, her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The client's parents are both healthy; no other family members have had these symptoms. What type of seizure disorder is most likely?

In an absence seizure there is no tonic-clonic activity. There is a sudden brief lapse of consciousness with blinking, staring, lip smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes with hyperventilation.

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function.

The nurse is testing for Brudzinski's sign in a newly admitted client. What would indicate meningeal inflammation?

Pain and flexion of the hips and knees are positive Brudzinski's signs. Pain and resistance to knee extension is a positive Kernig's sign. Pain in the neck and resistance to neck flexion is not part of Brudzinski's sign.

When performing the physical assessment of a client, the nurse notes the presence of a small cyst that contains hair, which is located midline in the sacrococcygeal area and has a palpable sinus tract. How should the nurse document this finding?

Pilonidal cyst

Prostate enlargement is common in older men. The nurse should be aware of what signs and symptoms when interviewing an older male client?

Sensation of residual urine Straining to urinate Dribbling

Which of the following male clients is most in need of immediate medical treatment?

Torsion of the spermatic cord, as exemplified by painful retraction of the testes in an adolescent, constitutes a medical emergency.

The cerebrum is divided into right and left hemispheres, which are joined together by the

corpus callosum.

The rectum is lined with folds of mucosa, and each fold contains a network of arteries, veins, and visceral nerves. When these veins undergo chronic pressure, the result may be

hemorrhoids

The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply

mental status cranial nerves motor system sensory system reflexes

A male client suffers from urinary retention. Which instructions are best to teach the client?

"Try voiding, then resting a few minutes, before going again."

A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?

"Walk across the room and back."

Upon inspection and palpation of the front of the client's thigh, the nurse discovers a bulge that appears when the client coughs. The nurse should document this finding as which type of hernia?

A bulge or mass on the front of the thigh in the femoral canal area is a femoral hernia. A hernia is strangulated if the blood supply is cut off. In this case, the client typically complains of extreme tenderness and nausea. A scrotal mass that remains when the client lies down and over which bowel sounds can be auscultated is a scrotal hernia. If the mass in the scrotum cannot be pushed into the abdomen, it could be an incarcerated hernia.

You are caring for a 33 year old male who has come to the clinic for a physical examination. He states that he has not had a routine physical in five years. During the examination the physician finds that digital rectal examination (DRE) reveals extensive hardening in the posterior lobe of the prostate gland that is not mobile. The nurse recognizes that the observation typically indicates what

A sign of early prostate cancer

When assessing the client, the nurse notes bradykinesia. The nurse would know that this abnormality is caused by damage to what?

Damage to the basal ganglia system produces changes in muscle tone (most often an increase), disturbances in posture and gait, a slowness or lack of spontaneous and automatic movements termed bradykinesia, and various involuntary movements.

A client makes this movement when the nurse assesses for the plantar response. What should this movement indicate to the nurse?

Dorsiflexion of the big toe and fanning of the other toes, is a "present" Babinski response, arising from a CNS lesion affecting the corticospinal tract. An expected response is plantar flexion with the toes curving down and inward. This movement does not indicate the presence of pain or hyperactive deep tendon reflexes.

A male client seeks medical attention for a swelling in the groin area. What should the nurse consider is occurring with this client?

Hernia Cancer Infection

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

If the anal sphincter tightens as the nurse palpates it, what should he or she do?

Pause, reassure the client, and proceed.

A nurse cares for an elderly client with right side hemiplegia and expressive aphasia. Which deficit should the nurse expect to find in the client?

Slow speech with appropriate meaning

During the physical assessment of a client's genitalia, the nurse notes an abnormal mass or swelling. The nurse performs transillumination by shining a light from the back of the scrotum through the mass. In which condition should the nurse see a red glow?

Spermatocele

The prostate functions to

The prostate secretes a thin, milky substance that promotes sperm motility and neutralizes female acidic vaginal secretions.

The cerebrospinal fluid cushions the central nervous system (CNS), provides nourishment to the CNS, and

The subarachnoid space is filled with cerebrospinal fluid (CSF), which is formed in the ventricles of the brain and flows through the ventricles into the space. This fluid-filled space cushions the brain and spinal cords, nourishes the CNS, and removes waste materials.

The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible

Transient blind spots may be an early sign of a cerebrovascular accident (CVA).

Which action by a nurse demonstrates the correct technique to use the reflex hammer?

Use rapid wrist movement and strike the tendon

A young man feels something in his scrotum and comes to you for clarification. On your examination, you feel what feels like a "bag of worms" in the left scrotum, superior to the testicles. Which of the following is most likely?

Varicocele

In a healthy man, which of the following anatomical components normally passes through the abdominal muscle by way of the inguinal canal?

Vas deferens

Which tests are appropriate for a nurse to perform to test cranial nerve VIII?

Whisper, Rinne, and Weber tests

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

patellar

The testes in the male scrotum are

suspended by the spermatic cord.

Upon inspection and palpation of the scrotum, the nurse discovers a mass. The client complains of tenderness in the area and nausea. The nurse is concerned that the blood supply to the mass may be cut off. The nurse should document this finding as which type of hernia?

A hernia is strangulated if the blood supply is cut off. In this case, the client typically complains of extreme tenderness and nausea. If you suspect that the client has a strangulated hernia, refer the client immediately to the physician and prepare him for surgery. A scrotal mass that remains when the client lies down and over which bowel sounds can be auscultated is a scrotal hernia. If the mass in the scrotum cannot be pushed into the abdomen, it could be an incarcerated hernia. A bulge or mass on the front of the thigh in the femoral canal area is a femoral hernia.

When assessing a client's coordination by asking the client to touch the nose with the finger, what should a nurse keep in mind about a client's movements?

A nurse should ask a client to touch the tip of the nose with the right index finger, then the left. This should be repeated three times. Movements should be smooth and performed without hesitation. The nurse should keep in mind that the client's dominant side will be more coordinated than the nondominant side. The elderly client may be slower but the movement should still be smooth and accurate. Movements should not become less accurate as the client repeats the maneuver.

A 41-year-old real estate agent comes to the office saying that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy; as the day progressed he could not close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. Past medical history is unremarkable. He is divorced with one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination the nurse asks the client to close his eyes. He cannot close his left eye. The nurse asks him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. The nurse then asks the client to give a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. What type of facial paralysis does he have?

A peripheral lesion will involve the entire side of the face. This causes the inability to close the eye, raise the eyebrow, wrinkle the forehead, and smile on the affected side. Bell's palsy is an example of this type of paralysis.

An experienced nurse is training a novice nurse on how to perform mental health assessments. The novice nurse asks the colleague exactly what "mental health" means. The experienced nurse responds by citing the 2010 definition of the World Health Organization (WHO), which states that mental health requires which of the following components?

A state of well-being Ability to cope with the normal stresses of life Ability to work productively Ability to make a contribution to one's community

The nurse is assessing a male client complaining of testicular pain. Which symptom helps the nurse determine that the client does not need immediate surgical intervention?

Absence of nausea and vomiting. Testicular torsion requires immediate surgical intervention. The signs of testicular torsion include: acute pain; nausea and vomiting in 50% of clients (nausea and vomiting are rare in epididymitis); rare fever; and urethral irritation.

A nurse is palpating the prostate of a client and finds it to be swollen, tender, firm, and warm to the touch. Which condition should the nurse most suspect?

Acute prostatitis

A 36-year-old married bank teller comes to the office complaining of pain with defecation and occasional blood on the toilet paper. She states that last week she had food poisoning with nausea, vomiting, and diarrhea. She had runny stools but no black or bloody stools. Since her illness, she has continued to have severe pain with bowel movements. She now tries to delay defecation as long as possible. Although she is having constipation, she denies any further diarrhea or leakage of stool. She has a past medical history of hypothyroidism and two spontaneous vaginal births. She has had no other chronic illnesses or surgeries. She does not smoke and rarely drinks. She has two children. There is no family history of breast or colon cancer. She has had no weight gain, weight loss, fever, or night sweats. On examination she is afebrile with a blood pressure of 123/70 and a pulse of 80. Abdominal examination reveals active bowel sounds, nontender in all quadrants, and no hepatosplenomegaly. Inspection of the anus reveals inflammation on the posterior side with erythema. Digital rectal examination is painful for the client, but no abnormalities are palpated. Anoscope examination reveals no inflammation or bleeding. What is the anal disorder that best describes her symptoms?

Anal fissure

The nurse is admitting a client new to the clinic who states, "My face feels funny." When the nurse assesses the client she finds isolated facial sensory loss to pain and no neurologic deficits in his extremities. What diagnosis would the nurse expect for this client?

Ask the client to report whether it is "sharp" or "dull" and to compare sides. Isolated facial sensory loss is seen in peripheral nerve disorders like trigeminal neuralgia.

While conversing with a 42-year-old client, the nurse notes the client's tendency to repeatedly wink and shrug his shoulders at irregular intervals. The movements do not appear to correlate with the client's conversation. How should the nurse best follow up this observation?

Assess the client's medication regimen and history of recreational drug use.

The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?

Aura

A 60-year-old coach comes to the clinic complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream, and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s, and the client's father is currently in his 80s with high blood pressure and arthritis. Examination reveals a mildly obese alert and cooperative man. His blood pressure is 130/70 with a heart rate of 80. He is afebrile, and his cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove. An analysis of the urine shows no red blood cells, white blood cells, or bacteria. What disorder of the anus, rectum, or prostate is most likely?

BPH becomes more prevalent during the fifth decade and is often associated with hesitancy in starting a stream, decreased strength of stream, nocturia, and leaking of urine. On examination an enlarged, symmetrical, firm prostate is palpated. The anterior lobe cannot be felt. These clients may also develop UTIs secondary to their obstruction.

A client reports that she is experiencing a tremor when she reaches for things. This worsens as she nears the "target." When the examiner asks the client to hold out her hands, no tremor is apparent. What type does this most likely represent?

Because it worsens as the target is approached, this represents an "intention" tremor. In this client, one may suspect cerebellar pathway disease, possibly from multiple sclerosis (one could also look for an intranuclear ophthalmoplegia). A postural tremor occurs when a certain position is maintained; resting tremors occur can occur with diseases such as Parkinson's. These do not occur during sleep.

A nurse assesses a client who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination?

Bell's palsy is a peripheral injury to cranial nerve VII (facial) that causes the inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face. Drooping of the eyelids (ptosis) is seen with weak eye muscles such as in myasthenia gravis. Limited lateral gaze of the eyes may indicate increased intracranial pressure. Paralysis of the lower lip is not seen in any common disorder of cranial nerve function.

A 72-year-old male presents at a local clinic and states: "I have to urinate all the time, and I never feel like my bladder is emptied. It really bothers me at night." What condition might the nurse suspect related to this chief complaint?

Benign prostatic hyperplasia (BPH)

A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?

Broca's area

Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation?

Dysarthria

When testing the biceps reflex, what type of response should the nurse expect if normal?

Elbow flexes and muscle contracts

Which of the following recommendations would a nurse advocate during infancy and childhood to help reduce potential adult complications such as orchitis?

Ensure immunizations against infectious diseases such as mumps.

Which of the following statements is true of prostate cancer?

Ethnicity is a risk factor.

A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?

Explanation: For clients with a high school education a score of 20-27 on the SLUMS exam indicates mild cognitive impairment (MCI) and for clients with less than high school education a score of 14-19 indicates MCI. For clients with a high school education a score of 1-19 indicates dementia and for clients with less than high school education a score of 1-14 indicates dementia.

A nurse examines the anal area of a client and observes the presence of a varicose vein. How should the nurse document this finding?

External hemorrhoid

The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience?

Following a spinal cord hemisection, pain and temperature sensation, are lost below the level of the injury or lesion on the opposite side of the body. Position sense, vibration, and motor function are affected on the same side of the body.

The nurse is preparing a presentation for a local community group about prostate cancer and possible dietary risk factors. Which of the following would the nurse most likely include?

High-fat diet

A 36-year-old security officer comes to the clinic with a painless mass in his scrotum. He found it 3 days ago during a self-testicular examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. Past medical history is notable for high blood pressure. He is married with three healthy children. He denies illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health; his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis he is circumcised with no lesions noted. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft, nontender cystic-like lesion measuring 2 centimeters over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight-bearing there are no bulges. His prostate examination is unremarkable. What disorder of the scrotum does he most likely have?

Hydrocele

An adolescent present at the free clinic with a collection of fluid in the tunica vaginalis of the testes. The nurse knows that the term that defines this condition is what?

Hydrocele

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

Hypothalamus

During the health history of the nervous system, a client report having a history of generalized seizures. Which of the following should the nurse ask the client to determine characteristic symptoms of the seizures?

If the client has had postictal state, this suggests generalized seizures. To assess characteristic symptoms of a generalized seizure, the nurse should ask the client what occurs after the seizure. Asking about the age at which the seizures began assesses the onset. Asking when the client last had a seizure also assesses the onset. Asking how often the seizures occur assesses the duration.

When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?

In clients with ataxia from loss of position sense, vision compensates for the sensory loss. A client who stands well with eyes open but loses balance with eyes closed is exhibiting a positive Romberg sign. Client safety, vestibular defects, or the effects of repetition do provide the rationale for conducting the Romberg test in the stated manner.

The nurse is assessing the genitalia of an adult male client when he tells the nurse that his testes are swollen and painful. The nurse should refer the client to a physician for possible

In epididymitis the scrotum appears enlarged, reddened, and swollen.

Upon inspection and palpation of the scrotum, the nurse discovers a mass. The nurse finds that the mass cannot be pushed back into the abdomen. The nurse should document this finding as which type of hernia?

Incarcerated

A nurse has begun a new job at a mental health facility. The supervisor is explaining to the nurse the features included in the definition of a mental disorder, according to the DSM-5. Which of the following should the supervisor mention to the nurse?

Is a behavioral or psychological syndrome or pattern that occurs in an individual Reflects an underlying psychobiologic dysfunction Results in clinically significant distress or disability

A nurse recognizes that which finding is normal upon palpation of the prostate?

Nontender and rubbery

A nurse performs a two-point discrimination test on a client who was in an automobile accident to assess for the presence of a lesion of the sensory cortex. The nurse touches the client's body at various sites on his right side with the two points of EKG calipers. Which finding, stated as the distance between the two points at which the client can no longer distinguish the two points as separate, would indicate an abnormal response on the part of the client?

Normal two-point discrimination findings on the right side include the following: 6 mm at the fingertips, 15 mm on the dorsal hand, 45 mm on the chest, and 40 mm on the upper arm. Thus, the finding of 20 mm on the dorsal hand is abnormal and may indicate a lesion of the sensory cortex.

A client presents to the emergency department after being hit in the face with a baseball. The health care provider orders vision testing to be performed to assess the whether the cranial nerves are intact. The nurse should prepare to test which cranial nerves?

Oculomotor Abducens Trochlear

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?

Older clients usually have deep tendon reflexes intact, although a decrease in reaction time may slow the response.

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?

Pain and flexion of the hips and knees is a positive Brudzinski sign that suggests meningeal inflammation. If the hips and knees remain relaxed and the neck is able to be flexed to the chest, the client is not demonstrating signs of meningeal irritation. Pain behind the knees when fully extended is a normal finding in some people.

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that a varicocele is present?

Palpable and tortuous veins

After completing the physical examination of the genitalia for an uncircumcised client, the nurse observes that the foreskin is too tight to be returned to cover the glans of the penis. How should the nurse document this condition?

Paraphimosis

An auditory hallucination is considered an alteration in which component of the mental health assessment?

Perception is the sensory awareness of objects in the environment and their interrelationships (external stimuli). Perception also refers to internal stimuli such as dreams or hallucinations. Thought processes involve the logic, coherence, and relevance of a client's thought as it leads to selected goals or how people think. Affect is the observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor. Insight is considered the awareness that symptoms or disturbed behaviors are normal or abnormal, for example, distinguishing between daydreams and hallucinations that seem real.

A nurse is instructing a client on how to perform testicular self-examination (TSE). Which of the following should the nurse mention?

Perform the TSE once a month Stand in front of a mirror and check for scrotal swelling Roll the testis gently in a horizontal plane between thumb and fingers

A nurse performs a neurological examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet?

Plantar flexion

On palpation of a client's prostate, a nurse detects hard, fixed, and irregular nodules on the prostate. Which condition should the nurse most suspect in this client?

Prostate cancer

Mr. Jackson, 50 years old, has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is the most likely diagnosis?

Prostatitis

The nurse is assessing a client exhibiting dystonic movements. The nurse should review the client's medications from home to check whether he is taking which medications that may cause the dystonia?

Psychiatric medications

A nurse is working with a client who suffered nerve damage during surgery for removal of a tumor. The client, who is an artist, lost fine motor control in his hands and can no longer manipulate a paintbrush. Which neural pathway should the nurse suspect to be damaged?

Pyramidal tract

A nurse prepares a male client for a physical assessment of the external genitalia. Which instruction is appropriate for the nurse to give the client before the examination?

Reassure him that it is not unusual to have an erection during the examination

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

Sensory function of the acoustic nerve is both hearing (cochlear division) and balance (vestibular division). The sensory function of the olfactory nerve is the sense of smell. The sensory function of the trigeminal nerve covers three areas of the face: around the eyes, along the maxilla, and along the mandible. The hypoglossal nerve does not have a sensory function.

A nurse educates a young male client on human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Which of the following should the nurse identify as potential risk factors?

Sharing intravenous needles Mixing of sex and alcohol or drugs Indulging in anal intercourse with men

The nurse prepares material to teach a group of adolescent male students on testicular self-examination. What should the nurse include in this teaching?

Stand in front of a mirror Perform the examination one a month Complete the examination after a warm bath or shower Use the thumb, and index and middle finger for the examination

A client reports the new onset of mucous in the stool. How should the nurse document this in the client's history?

Steatorrhea

A 21-year-old engineering student comes to your office complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific traumatic incidences, but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait the nurse notices that the client has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely have?

Steppage gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc.

The nurse is conducting an examination of an adult male's genitalia during his annual physical examination. The client has an erection and the nurse reassures him that this is a normal physiologic response and continues the examination. Why would the nurse continue with the examination at this time?

Stopping could cause further embarrassment.

After teaching a group of student about structural abnormalities of the male reproductive system, the instructor determines that the teaching was successful when the students identify which of the following as an example?

Structural abnormalities include cryptorchidism, torsion of the spermatic cord, phimosis, paraphimosis, hydrocele, spermatocele, and varicocele.

The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?

Swaying

Upon assessment, the nurse suspects the client is having a stroke. What symptoms might the nurse have found?

Symptoms of a stroke appear suddenly and include numbness or weakness of the face, arm or leg, confusion, difficulty speaking or understanding speech, and difficulty walking, or loss of balance. An unsteady gait and tremors would not be symptoms of a stroke.

A 28-year-old musician comes to the clinic complaining of a "spot" on his penis. He states his partner noticed it 2 days ago and it hasn't gone away. He says it doesn't hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. He denies any surgeries. He smokes two packs of cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He has injected IV drugs before but not in the last few years. His mother has rheumatoid arthritis; he doesn't know anything about his father. Examination shows a young man appearing deconditioned but pleasant. His vital signs are unremarkable. Visualization of his penis reveals a 6-mm red, oval ulcer with an indurated base just proximal to the corona. There is no prepuce because of neonatal circumcision. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy. What disorder of the penis is most likely?

Syphilitic chancre

The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's

Test sensitivity to position. Ask the client to close both eyes. Then hold the client's toe or a finger on the lateral sides and move it up or down. Ask the client to tell you the direction it is moved. Repeat on the other side.

On inspection and palpation, the nurse finds that a client's testes are small, probably less than 2 cm, and firm. Which of the following conditions should the nurse most suspect in this situation?

Testes that are less than 2 cm long and firm may indicate Klinefelter's syndrome.

A client presents at the clinic with severe scrotal pain. What is the presumptive diagnosis?

Testicular torsion

The nurse is caring for a client who suffered a stroke and is able to carry out simple instructions correctly but has trouble writing responses to questions. The nurse plans to review the client's MRI report of the brain and expects to find that which area of the brain has been adversely affected?

The Wernicke area integrates understanding of spoken and written words, whereas the Broca area regulates verbal expression and writing ability. The primary visual area is the occipital lobe at the back of the brain, with visual associative areas that interpret and integrate stimuli. The temporal lobe registers auditory input and is responsible for hearing, speech, behavior, and memory.

A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?

The corneal reflex test is done to assess the sensory portion of cranial nerve V (trigeminal). If the client has an intact nervous system, the nurse should ask about the presence of contact lenses because they can cause the reflex to be absent or reduced. Touching the cornea with a small piece of cotton is how the test is performed. Blinking or rinsing the eyes is not an appropriate action.

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?

The glossopharyngeal nerve (cranial nerve IX) contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the "gag reflex" when stimulated. The vagus nerve (cranial nerve X) carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera and promotes swallowing, talking, and production of digestive juices. The spinal accessory nerve (cranial nerve XI) innervates neck muscles (sternocleidomastoid and trapezius) that promote movement of the shoulders and head rotation and promotes some movement of the larynx. The hypoglossal nerve (cranial nerve XII) innervates tongue muscles that promote the movement of food and talking.

The hypothalamus is responsible for regulating

The hypothalamus (part of the autonomic nervous system, which is a part of the peripheral nervous system) is responsible for regulating many body functions including water balance, appetite, vital signs (temperature, blood pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional status.

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

The motor function of the trigeminal nerve includes the temporal and masseter muscles, both used with jaw clenching. The motor function of the facial nerve controls facial expression and closing the eyes and the mouth. The motor function of the glossopharyngeal nerve controls the pharynx. The motor function of the vagus nerve controls the palate, pharynx, and larynx.

A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?

The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal such as with the experience of anxiety. The peripheral nervous system supplies nerve stimulation to the heart, visceral organs, skin, and the extremities. The autonomic nervous system connects to internal organs and generates autonomic reflex responses. The somatic nervous system regulates muscle movements and response to sensations of touch and pain.

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type?

This is a common description and scenario for absence seizures, which are generally brief (fewer than 10 seconds, "petit mal"). They generally occur without warning and do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic-clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the client speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use.

The client is diagnosed with a peripheral neuropathy. The nurse knows that often the first sensation lost in a peripheral neuropathy is what?

Vibration sense is often the first sensation to be lost in a peripheral neuropathy.

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?

Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.

Which area of the brain integrates the understanding of spoken and written words?

Wernicke's area integrates the understanding of spoken and written words, while Broca's area regulates verbal expression and writing ability. The basal ganglia controls voluntary motor movements, cognition, and emotion. The cerebrum is the part of the brain that contains the cerebral cortex, hippocampus, basal ganglia, and olfactory bulb.

When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus?

When assessing the level of consciousness, the nurse should begin with the least noxious stimulus which is verbal, and then proceed to tactile, to painful. The client may just need the command to be given louder or in a lower tone of voice.

When providing client teaching, what can the nurse assess?

You use assessment information to identify client outcomes. An outcome related to neurological problems include: Patient improves motor function and becomes independent with activities of daily living (ADLs).

The nurse suspects that a male client may have a hernia. The nurse should further assess the client for

bowel sounds at the bulge.

The nurse has assessed a male client and determines that one of the testes is absent. The nurse should explain to the client that this condition is termed

cryptorchidism.

Prostate cancer is the leading cancer diagnosed in men in the United States. To increase knowledge of risk factors, the nurse would teach men that

each decade after age 50 increases the risk it occurs earlier and is more advanced in African American men 15% have an affected first-degree relative

A client visits the clinic and tells the nurse that her stools have been black for the past 3 days. The nurse should assess the client for

gastrointestinal bleeding.

The corpora spongiosum extends distally to form the acorn-shaped

glans

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the

gray matter

During assessment of an adult client, which of the following lifestyle practices would indicate to the nurse that the client may be at high risk for HIV/AIDS? A client who

has anal intercourse with other males.

A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior?

parasympathetic; The parasympathetic nervous system conserves energy and resources during times of rest and relaxation. The central nervous system consists of the brain and spinal cord. The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal. The cranial nerves emerge from within the cranial vault through skull foramina and canals to structures in the head and neck.

Which body functions are related to the hypothalamus?

sweating on a hot day feeling worried about an exam experiencing a regular menstrual cycle

What should the nurse assess to test the function of the parietal lobe?

tactile sensation

The diencephalon of the brain consists of the

thalamus and hypothalamus.