A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Review the client's serum electrolytes.

Evaluate client's muscle strength and hand grips.

Check distal phalanges capillary refill.

Observe skin for erythema, edema, and warmth.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Reviewing the client's serum electrolytes is incorrect. While abnormalities in electrolyte levels can sometimes contribute to neurological symptoms, such as paresthesia, reviewing the client's serum electrolytes may not directly identify additional findings consistent with the client's reported paresthesia of the hands and legs. Therefore, this option is less relevant for assessing paresthesia and identifying additional consistent findings.
Choice B Reason:
This is the correct action to identify additional findings consistent with the client's paresthesia. Paresthesia, or abnormal sensations like burning or tingling, may indicate neurological dysfunction. Assessing the client's muscle strength and hand grips can provide valuable information about neurological function and help identify any weakness or changes that may be associated with the paresthesia.
Choice C Reason:
Checking distal phalanges capillary refill is incorrect. Checking distal phalanges capillary refill is important for assessing peripheral circulation, but it may not directly identify additional findings consistent with paresthesia. While impaired circulation could contribute to sensory disturbances, such as paresthesia, it is not always the primary cause. Therefore, this option may not fully capture the sensory aspect of the client's reported symptoms.
Choice D Reason:
While observing the skin for signs of inflammation or irritation is important in assessing for other conditions, such as infection or inflammation, it is not directly related to identifying additional findings consistent with paresthesia. Paresthesia primarily involves abnormal sensations and neurological function rather than changes in the skin.

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Correct Answer is C

Explanation

Choice A Reason:
Giving the client an object to hold is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While providing an object to hold may engage the muscles, it does not specifically target the muscles involved in arm flexion, which are primarily the biceps brachii and brachialis muscles. Therefore, it may not accurately assess muscle strength during arm flexion.
Choice B Reason:
Instructing the client to close his eyes is not the most appropriate action before asking the client to flex his arms to assess muscle strength. Instructing the client to close his eyes primarily tests proprioception and balance rather than muscle strength. While proprioception is an important aspect of overall neurological function, it is not directly related to assessing muscle strength during arm flexion.
Choice C Reason:
Applying resistance to the client's arms is the most appropriate action before asking the client to flex his arms to assess muscle strength. Applying resistance to the client's arms during flexion allows the nurse to evaluate the client's ability to generate force against resistance, providing a more accurate assessment of muscle strength in the biceps brachii and brachialis muscles.
Choice D Reason:
Palpating the client's muscle tone is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While palpating muscle tone is important for assessing muscle integrity, it does not directly evaluate muscle strength during arm flexion. Muscle tone refers to the resting tension in a muscle and may not accurately reflect muscle strength during active movement.

A. Syncope. B. Acute pain. C. Tetany. D. Dyspnea.

Correct Answer is D

Explanation

Choice A Reason:
Syncope is incorrect. Syncope, or fainting, can occur in individuals experiencing severe respiratory distress or hypoxia. Pursed-lip breathing is often used as a technique to manage dyspnea and improve oxygenation, which can help prevent syncope by ensuring adequate ventilation and oxygen delivery to the body's tissues. However, syncope is not the primary concern associated with the observation of pursed-lip breathing; instead, it is a potential consequence of inadequate oxygenation.
Choice B Reason:
Acute pain is not directly related to the observation of pursed-lip breathing. Pursed-lip breathing is a technique used to manage dyspnea and improve ventilation efficiency in individuals with respiratory conditions such as chronic obstructive pulmonary disease (COPD) or asthma exacerbation. While pain can exacerbate respiratory distress in some cases, the primary focus when observing pursed-lip breathing is to assess and address respiratory status rather than pain management.
Choice C Reason:
Tetany is incorrect. Tetany, characterized by muscle spasms due to low calcium levels, is not directly associated with the observation of pursed-lip breathing. Pursed-lip breathing is a respiratory technique used to manage dyspnea and improve ventilation in individuals with respiratory conditions such as COPD or asthma. While respiratory distress can lead to various physiological responses, tetany is not a typical manifestation observed in individuals using pursed-lip breathing.
Choice D Reason:
Dyspnea is correct. Pursed-lip breathing is a technique often used by individuals with respiratory conditions to relieve shortness of breath and improve breathing efficiency. The primary reason for using pursed-lip breathing is to help alleviate dyspnea, or difficulty breathing, by promoting more effective exhalation and preventing airway collapse during expiration. Monitoring for dyspnea is crucial in this situation to assess the client's respiratory status, including the severity of breathing difficulty and any associated symptoms, and to guide further interventions to address the underlying cause of dyspnea. While syncope (fainting), acute pain, and tetany (muscle spasms due to low calcium levels) are potential concerns in certain clinical contexts, they are not directly associated with the observation of pursed-lip breathing. Therefore, dyspnea is the most relevant problem for the nurse to monitor in this scenario.

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A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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