NUR 265 – EXAM 3 Review |
Questions and Answers | 2025 Update | 100%
Correct.
1. ASSESSING FOR RECENT MEMORY
The nurse assesses a client's recent memory. Which statement by the client confirms 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."
2. TBI – WHICH ASSESSMENT FINDING TO REPORT TO MD
A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment
finding would be the priority for the nurse to report to the primary health care provider?
a. Mild temporal headache
b. Pupils equal and react to light
c. Alert and oriented x 3
d. Decreasing level of consciousness
3. LETHARGIC
When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily
aroused. What level of consciousness will the nurse document to describe this client's current level of
consciousness?
a. Alert
b. Lethargic
c. Stuporous
d. Comatose
4. CRANIAL NERVE 5 – ASSESSMENT FINDING
The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment
findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain
5. CRANIAL NERVE 3 – WHICH TEST
The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language
6. PAIN DISCRIMINATION – TEST
A nurse performs an assessment of pain discrimination on an older adult. The client correctly identifies, with
eyes closed, a sharp sensation on the right hand when touched with a pin. Which action nurse takes next?
a. Touch the pin on the same area of the left hand.
b. Contact the primary health care provider with the assessment results.
c. Ask the client about current and past medications.
d. Continue the assessment on the client's feet and legs.
7. LP – ASSESSMENT FINDING NURSE WOULD REPORT
A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the nurse to contact
, the primary health care provider?
a. Shingles infection on the client's back
b. Client is claustrophobic
c. Absence of intravenous access
d. Paroxysmal nocturnal dyspnea
Questions and Answers | 2025 Update | 100%
Correct.
1. ASSESSING FOR RECENT MEMORY
The nurse assesses a client's recent memory. Which statement by the client confirms 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."
2. TBI – WHICH ASSESSMENT FINDING TO REPORT TO MD
A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment
finding would be the priority for the nurse to report to the primary health care provider?
a. Mild temporal headache
b. Pupils equal and react to light
c. Alert and oriented x 3
d. Decreasing level of consciousness
3. LETHARGIC
When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily
aroused. What level of consciousness will the nurse document to describe this client's current level of
consciousness?
a. Alert
b. Lethargic
c. Stuporous
d. Comatose
4. CRANIAL NERVE 5 – ASSESSMENT FINDING
The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment
findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain
5. CRANIAL NERVE 3 – WHICH TEST
The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language
6. PAIN DISCRIMINATION – TEST
A nurse performs an assessment of pain discrimination on an older adult. The client correctly identifies, with
eyes closed, a sharp sensation on the right hand when touched with a pin. Which action nurse takes next?
a. Touch the pin on the same area of the left hand.
b. Contact the primary health care provider with the assessment results.
c. Ask the client about current and past medications.
d. Continue the assessment on the client's feet and legs.
7. LP – ASSESSMENT FINDING NURSE WOULD REPORT
A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the nurse to contact
, the primary health care provider?
a. Shingles infection on the client's back
b. Client is claustrophobic
c. Absence of intravenous access
d. Paroxysmal nocturnal dyspnea
