Author Question: The nurse is assessing the client's neurologic system. The nurse tests the client's ability to ... (Read 106 times)

strangeaffliction · **on:** Jun 25, 2018

The nurse is assessing the client's neurologic system. The nurse tests the client's ability to perform stereognosis. Which activity will accurately test this?

1. The nurse places a vibrating tuning fork over the client's ankle and asks the client to indicate when the vibration can no longer be felt.
2. The nurse asks the client to close her eyes and writes the number '7' in the client's palm with the base of the nurse's pen. The nurse asks the client to identify what was written.
3. The nurse asks the client to close her eyes and places a pen in the client's hand. The nurse asks the client to name the object in her hand.
4. The nurse asks the client to close her eyes and indicate where the nurse is touching the client.

Question 2

The nurse is performing a physical assessment for the client and identifies a venous hum while auscultating the client's abdomen. Which statement by the nurse is the most consistent with this type of vascular sound?

1. The sound is a blowing, pulsing sound.
2. The sound is soft and constant. The pitch of the sound is low.
3. It is grating, rough sound.
4. It is tinkling and has a high pitch. The sound is sort of gurgling and irregular.

annierak · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3
Stereognosis is the ability to identify an object without seeing it. The inability to identify a familiar object could indicate cortical disease. Vibratory sense is the test to identify if the client can perceive vibration. The inability to perceive vibration may indicate neuropathy. Graphesthesia is the ability to perceive writing on the skin. The inability to perceive a number on the skin may indicate cortical disease. Topognosis is the ability of the client to identify an area of the body that has been touched. The inability of the client to identify a touched area demonstrates sensory or cortical disease.

Answer to Question 2

Correct Answer: 2
Vascular sounds include bruits and venous hum. A venous hum is soft, continuous, and low-pitched. A bruit is pulsatile and blowing. A friction rub refers to a rough, grating sound caused by the rubbing together, of organs or an organ rubbing on the peritoneum. The normal bowel sounds heard upon auscultation of the abdomen are irregular, high-pitched, gurgling sounds.