Nokea
While Susan's medication is being adjusted, which of the following aspects of nursing assessment would be most important to document?
- A. Muscular strength following medication administration
- B. Elimination patterns
- C. Emotional response to her diagnosis
- D. State of consciousness
Correct Answer: A
Rationale: Muscle strength is directly affected by myasthenia gravis and its treatment.
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When performing a neurologic assessment, the nurse should prioritize:
- A. Observing for any sudden changes in mental status or physical function.
- B. Measuring the patient's body temperature.
- C. Checking the patient's blood pressure.
- D. Assessing the patient's respiratory rate.
Correct Answer: A
Rationale: Sudden changes in mental status or physical function are critical in neurologic assessments. Temperature, blood pressure, and respiratory rate are secondary considerations.
Which of the following clients are more likely to suffer from a cerebral hematoma?
- A. A client with a family history of hemophilia; no symptoms
- B. A client receiving platelets for a low platelet count
- C. A client with anemia taking iron
- D. A client with atrial fibrillation on Coumadin
Correct Answer: D
Rationale: Clients on anticoagulants are at higher risk for bleeding complications.
What is a consequence related to rigidity?
- A. Shuffling gait
- B. Impaired handwriting
- C. Lack of postural stability
- D. Muscle soreness and pain
Correct Answer: A
Rationale: Rigidity contributes to a shuffling gait in Parkinson's disease
An older female client experiences a musculoskeletal injury to her hip. Which of the following methods would help a nurse identify any swelling in the client?
- A. Asking questions of the client to assess the severity of pain
- B. Palpating the muscles and joints
- C. Asking the client to move the injured area as much as possible
- D. Observing the client for any involuntary movements
Correct Answer: B
Rationale: Palpation is a direct method to assess swelling and other physical changes.
For a patient with a one-sided spinal injury, the nurse must be careful about the temperature of the bath water because the patient's temperature sensation is lost
- A. contralaterally below the injury
- B. ipsilaterally below the injury
- C. bilaterally below the injury
- D. contralaterally above the injury
Correct Answer: A
Rationale: Temperature sensation is lost contralaterally below the injury level.