Question

The nurse cares for a client with an embolic stroke and assesses for PERRLA. What instruction should the nurse give to the client to assess the PERLA?

Answer 1

Correct Answers:

“Keep your eyes open, and Ill shine this light in your eyes.”

Rationale :

👁️PERRLA means Pupils Equal, Round, Reactive to Light and Accommodation, and the light reflex is central to this assessment.

🔦When the nurse shines a light into the client’s eyes, it directly evaluates pupil constriction, confirming reactivity to light.

📏Accommodation is assessed by shifting focus from far to near, but light testing remains the main step in PERRLA.

🚫Options involving eye tracking, eye covering, or distant focus test extraocular movement or visual acuity, not pupil light reaction.

📌Core Message

To assess PERRLA, the nurse shines a light into the eyes to observe pupil reaction to light.

Answer 2

Correct Answers:

Use of the prescribed antifungal medication.

Rationale :

🦶Onychomycosis is a fungal nail infection, and first-line management is topical or oral antifungal therapy as prescribed by the provider.

🧴Education focuses on adherence, expected duration of therapy, and hygiene measures (keep feet dry, change socks, avoid occlusive footwear) to enhance treatment effectiveness and reduce recurrence.

💊Antibiotics target bacterial infections and are not effective for fungal nail disease, so routine antibiotic completion counseling is not appropriate here.

🔪Surgical nail removal is generally reserved for refractory or severe cases; most patients improve with pharmacologic antifungals and foot-care education.

📌Core Message

For presumed onychomycosis, prioritize antifungal therapy and adherence education rather than antibiotics or immediate surgery.

Answer 3

Correct Answers:

Abdominal inspection.
History of nausea and vomiting.
Condition of teeth.
Color of stools.

Rationale :

👀A GI-focused assessment includes abdominal inspection for contour, distension, scars, and visible peristalsis as core inspection data.

🤢A history of nausea and vomiting provides essential subjective information about upper GI pathology and hydration and electrolyte risk.

🦷The condition of teeth informs nutritional status and chewing effectiveness, which directly impacts ingestion and digestion.

💩The color of stools reflects biliary function, GI bleeding, and malabsorption, making it a critical GI symptom review item.

💧Urine color is primarily genitourinary, not GI, and is therefore not a required element of the GI-focused exam.

📌Core Message

A proper GI assessment emphasizes abdominal exam, GI symptoms, oral health, and stool characteristics—not urinary findings.

Answer 4

Correct Answers:

Burning and numbness in the hands.

Rationale :

✋Phalen’s test reproduces median nerve compression symptoms when wrists are flexed, indicating potential carpal tunnel syndrome.

🔥An abnormal result is paresthesia (burning, numbness, tingling) in the median nerve distribution of the hand.

🟦Cyanosis is a vascular sign, not characteristic of median neuropathy provoked by Phalen’s maneuver.

💪Proximal weakness of the shoulders and generalized fatigue are nonspecific and do not localize to the carpal tunnel.

📌Core Message

A positive Phalen’s produces paresthesia in the median nerve territory—not vascular discoloration or proximal weakness.

Answer 5

Correct Answers

Blank 1 Correct Option: postoperative pain
Blank 2 Correct Option: analgesia

Rationale :

❤️The 1610 vitals show tachycardia (HR 116) with elevated pain (8/10), supporting sympathetic activation due to acute pain.

🩸No clear evidence of hemorrhage is provided beyond mild anemia; trends or active bleeding signs would be needed to prioritize blood products.

🦠Although the wound is erythematous, the temperature is normal and WBC is within range, making infection a less likely immediate cause of tachycardia.

💊The most direct treatment for pain-induced tachycardia is analgesia, which reduces sympathetic drive and can improve hemodynamics.

📌Core Message

Tachycardia linked to severe pain warrants analgesia before considering fluids or blood products.

Answer 6

Correct Answers:

Strong odor of urine on clothing.

Rationale :

👃A strong urine odor on clothing indicates recent leakage, suggesting urge or functional incontinence that can precipitate slips.

🧻Wearing an adult brief alone does not confirm incontinence-related etiology; briefs may be used prophylactically.

🦯Use of a cane and a slow gait reflect mobility status but are nonspecific for incontinence-related falls.

🚿Wet bathroom floors are often linked to incontinence episodes, so corroborating urine odor strengthens the causal connection.

📌Core Message

A urine odor on clothing strongly suggests incontinence-related risk contributing to the fall.

Answer 7

Correct Answers:

Complete assessment then report the finding to the health care provider immediately.

Rationale :

🩸Petechiae may indicate thrombocytopenia or bleeding disorders, requiring urgent provider notification after verifying extent and associated signs.

🧪Rapid assessment should include medications (e.g., anticoagulants), bleeding history, and other hemorrhagic findings for safe triage.

🧑‍⚕️Referring to wound care is misdirected, as this is a systemic hematologic concern rather than a skin-care issue.

📝Simply documenting without escalation risks delayed intervention for a potentially life-threatening coagulopathy.

📌Core Message

Diffuse petechiae warrant prompt assessment and immediate provider notification for potential coagulopathy.

Answer 8

Correct Answers:

“Does the pain move to any other place, or is it just in one spot?”
“Can you describe for me what the pain feels like?”
"Can you think of anything that makes the pain better or worse?”
“Can you remember what you were doing when you first felt the pain?'
Does the pain prevent you from doing any activities at home?”

Rationale :

🧭A thorough pain history uses OPQRST (onset, provocation/palliation, quality, region/radiation, severity, timing), covering all listed questions.

🗺️Asking if pain moves localizes region/radiation, helping differentiate joint from referred pain.

🎯Clarifying quality and triggers (better/worse) refines differential diagnosis and guides targeted management.

🏠Evaluating functional impact and onset context informs severity, safety, and necessary interventions or referrals.

📌Core Message

Use OPQRST to capture location/radiation, quality, provocation/palliation, onset, and functional impact.

Answer 9

Correct Answers:

Sensory assessment
Facial assessment
Grip strength

Rationale :

🧠Persistent facial asymmetry indicates ongoing neurologic deficit, essential for baseline trending and safety planning.

✋Marked grip strength asymmetry (R 1/5) signals significant motor impairment, elevating fall and aspiration risk during care activities.

👁️Sensory/visual deficits (e.g., partial hemianopia) increase injury risk and complicate rehabilitation, warranting prioritized assessment and precautions.

🍽️NPO status and hypoactive bowel sounds are expected in early stroke care and less urgent than deficits impacting airway/safety; glucose 127 mg/dL is not emergent.

📌Core Message

Focus first on neurologic deficits—facial droop, motor weakness, and sensory/visual loss—for safety and care planning.

Answer 10

Correct Answers:

Aspiration pneumonia
Dysphagia
Pressure injury
Communication deficits

Rationale :

🥤Dysphagia after stroke predisposes to aspiration and subsequent pneumonia, making both high-priority risks.

🛏️Immobility from hemiparesis raises risk for pressure injuries without aggressive repositioning and skin care.

🗣️Aphasia or dysarthria are common, leading to communication deficits that impact safety and education.

🧃Fluid volume excess and bowel obstruction are not typical early post-CVA risks compared to the listed neurologic sequelae.

📌Core Message

Expect dysphagia/aspiration, pressure injury, and communication deficits as key post-stroke risks.

Time	Blood Pressure	Heart rate	Respiratory Rate	Temperature	SpO2	Pain
0746	119/81	87	18	98.8°F (37.1°C)	97% RA	3/10
1200	125/78	72	16	98.5°F (36.9°C)	95% RA	2/10
1610	152/91	116	24	98.6°F (37°C)	97% RA	8/10

LAB	Reference Range	5/14
White Blood Cells (WBC)	4,000 -10,000 mm3	9500
Hemoglobin (Hgb)	12-17 g/dL	10
Hematocrit (Hct)	36-51 %	32
Sodium	135-145 mEq/L	133

NPH Stroke Scale
Category	Scale	Client Store
1a Level of consciousness	0 = Alert; keenly responsive 1 = Not alert; but arousable by minor stimulation 2 = Not alert; requires repeated stimulation 3 = Responds only with reflex or totally unresponsive	1
1b Level of consciousness questions	0 = Answers both questions correctly 1 = Answers one question correctly 2 = Answers neither question correctly	0
1c Level of consciousness commands	0 = Performs both tasks correctly 1 = Performs one tasks correctly 2 = Performs neither task correctly.	0
2 Best gaze	0 = Normal 1 = Partial gaze palsy 2 = Forced deviation	0
3 Visual	0 = No visual loss 1 = Partial hemianopia 2 = Complete hemianopia 3 = Bilateral hemianopia	1
4 Facial palsy	0 = Normal symmetrical movements 1 = Minor paralysis 2 = Partial paralysis 3 = Complete paralysis of one or both sides	1
5 Motor arm	0 = No drift 1 = Drift 2 = Some effort against gravity 3 = No effort against gravity 4 = No movement UN = Amputation or joint fusion explain	3
6 Motor leg	0 = No drift 1 = Drift 2 = Some effort against gravity 3 = No effort against gravity 4 = No movement UN = Amputation or joint fusion explain	3
7 Limb ataxia	0 = Absent 1 = Present in one limb 2 = Present in two limbs UN = Amputation of joint fusion explain	2
10 Dysarthria	0 = Normal 1 = Mild-to moderate dysarthria 2 = Severe dysarthria UN = Intubated or other physical barrier explain	1
11 Extinction and Inattention	0 = No abnormality 1 = Visual, tactile, auditory, spatial, or personal inattention

NPH Stroke Scale
Category	Scale	Client Store
1a Level of consciousness	0 = Alert; keenly responsive 1 = Not alert; but arousable by minor stimulation 2 = Not alert; requires repeated stimulation 3 = Responds only with reflex or totally unresponsive	1
1b Level of consciousness questions	0 = Answers both questions correctly 1 = Answers one question correctly 2 = Answers neither question correctly	0
1c Level of consciousness commands	0 = Performs both tasks correctly 1 = Performs one tasks correctly 2 = Performs neither task correctly.	0
2 Best gaze	0 = Normal 1 = Partial gaze palsy 2 = Forced deviation	0
3 Visual	0 = No visual loss 1 = Partial hemianopia 2 = Complete hemianopia 3 = Bilateral hemianopia	1
4 Facial palsy	0 = Normal symmetrical movements 1 = Minor paralysis 2 = Partial paralysis 3 = Complete paralysis of one or both sides	1
5 Motor arm	0 = No drift 1 = Drift 2 = Some effort against gravity 3 = No effort against gravity 4 = No movement UN = Amputation or joint fusion explain	3
6 Motor leg	0 = No drift 1 = Drift 2 = Some effort against gravity 3 = No effort against gravity 4 = No movement UN = Amputation or joint fusion explain	3
7 Limb ataxia	0 = Absent 1 = Present in one limb 2 = Present in two limbs UN = Amputation of joint fusion explain	2
10 Dysarthria	0 = Normal 1 = Mild-to moderate dysarthria 2 = Severe dysarthria UN = Intubated or other physical barrier explain	1
11 Extinction and Inattention	0 = No abnormality 1 = Visual, tactile, auditory, spatial, or personal inattention

1 :
The nurse cares for a client with an embolic stroke and assesses for PERRLA. What instruction should the nurse give to the client to assess the PERLA?

2 :
The client whose toe is shown in the image, is waiting to see the health care provider (HCP). what education does the nurse anticipate providing to the client after the HCP sees the client?

3 :
The nurse performs a focused assessment of the gastrointestinal system. What assessments must the nurse perform? Select all that apply.

4 :
When the nurse asks the client with suspected carpal tunnel syndrome to perform the test shown in the image, what is an abnormal finding?

5 :
The nurse cares for a client in the surgical unit.

Correct Answers

7 :
When the nurse performs a skin assessment on a young client newly admitted to the unit and finds petechiae in the client’s mouth and all over the abdomen what is the priority nursing action?

8 :
A client presents to the urgent care center with report of joint pain to bilateral upper extremities. What assessment question is important for the nurse to ask the client? Select all that apply.

9 :
A Nurse is attending to a client.

Answer Options

10 :
The nurse cares for a client post-cerebrovascular accident.

Answer Options

1 : The nurse cares for a client with an embolic stroke and assesses for PERRLA. What instruction should the nurse give to the client to assess the PERLA?

2 : The client whose toe is shown in the image, is waiting to see the health care provider (HCP). what education does the nurse anticipate providing to the client after the HCP sees the client?

3 : The nurse performs a focused assessment of the gastrointestinal system. What assessments must the nurse perform? Select all that apply.

4 : When the nurse asks the client with suspected carpal tunnel syndrome to perform the test shown in the image, what is an abnormal finding?

5 : The nurse cares for a client in the surgical unit.

Correct Answers

7 : When the nurse performs a skin assessment on a young client newly admitted to the unit and finds petechiae in the client’s mouth and all over the abdomen what is the priority nursing action?

8 : A client presents to the urgent care center with report of joint pain to bilateral upper extremities. What assessment question is important for the nurse to ask the client? Select all that apply.

9 : A Nurse is attending to a client.

Answer Options

10 : The nurse cares for a client post-cerebrovascular accident.

Answer Options

1 :
The nurse cares for a client with an embolic stroke and assesses for PERRLA. What instruction should the nurse give to the client to assess the PERLA?

2 :
The client whose toe is shown in the image, is waiting to see the health care provider (HCP). what education does the nurse anticipate providing to the client after the HCP sees the client?

3 :
The nurse performs a focused assessment of the gastrointestinal system. What assessments must the nurse perform? Select all that apply.

4 :
When the nurse asks the client with suspected carpal tunnel syndrome to perform the test shown in the image, what is an abnormal finding?

5 :
The nurse cares for a client in the surgical unit.

7 :
When the nurse performs a skin assessment on a young client newly admitted to the unit and finds petechiae in the client’s mouth and all over the abdomen what is the priority nursing action?

8 :
A client presents to the urgent care center with report of joint pain to bilateral upper extremities. What assessment question is important for the nurse to ask the client? Select all that apply.

9 :
A Nurse is attending to a client.

10 :
The nurse cares for a client post-cerebrovascular accident.