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 D

Explanation

a. "Motor responses."Motor responses are important in assessing neurological function, but they are typically assessed after determining the client's overall level of consciousness and alertness. Motor responses are usually assessed when the client is unresponsive or has altered consciousness.

b. "Eye opening."Eye opening is part of the Glasgow Coma Scale (GCS) and is an important indicator of neurological function. However, it is generally assessed after determining the client's level of alertness.

c. "Verbal response."Verbal response is another component of the GCS, assessing how the client responds to verbal stimuli. This assessment also follows the initial determination of the client’s alertness.

d. "Level of alertness."The level of alertness is the first and most fundamental aspect to assess because it gives the nurse a baseline understanding of how aware the client is of their surroundings. This assessment sets the stage for further evaluation of motor, eye, and verbal responses. It helps determine the client's ability to interact and respond to stimuli, guiding subsequent assessments.

A. Chronic pancreatitis. B. Peptic ulcer disease (PUD). C. Esophagitis. D. Gastroesophageal reflux (GERD).

Correct Answer is B

Explanation

Choice A Reason:
Chronic pancreatitis is incorrect. Chronic pancreatitis typically presents with persistent, dull abdominal pain that may radiate to the back, often aggravated by eating rather than relieved by it. The pain associated with chronic pancreatitis is not typically described as gnawing or relieved by eating.
Choice B Reason:
Peptic ulcer disease (PUD) is correct. Peptic ulcer disease involves the development of open sores (ulcers) in the lining of the stomach (gastric ulcers) or the upper part of the small intestine (duodenal ulcers). The pain associated with PUD typically occurs in the epigastric region (upper abdomen) and can be described as gnawing, burning, or dull. The pain tends to worsen when the stomach is empty (hunger pains) and is relieved by eating or taking antacids. These symptoms are due to the increase in gastric acid secretion, which exacerbates the ulcer's irritation when the stomach is empty and is neutralized when food buffers the acid. Therefore, the presentation described is consistent with peptic ulcer disease (PUD).
Choice C Reason:
Esophagitis is incorrect. Esophagitis is inflammation of the esophagus and may present with symptoms such as heartburn, difficulty swallowing, or chest pain behind the breastbone. However, the symptoms described, particularly the worsening of pain when hungry and improvement after eating, are not typical of esophagitis.
Choice D Reason:
Gastroesophageal reflux (GERD) is incorrect. While gastroesophageal reflux disease (GERD) can cause epigastric discomfort or heartburn, the symptoms described in the scenario are more indicative of pain related to hunger and relief after eating, which is more characteristic of peptic ulcer disease (PUD). Additionally, GERD symptoms are typically worsened by eating, lying down, or bending over, rather than improved.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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