A nurse is assessing a client who has a rotator cuff injury. Which of the following findings should the nurse expect?
Difficulty with abduction of the arm at the shoulder.
Alteration in the contour of the joint.
Positive Tinel's sign.
Negative drop arm test.
The Correct Answer is A
Choice A reason:
Difficulty with abduction of the arm at the shoulder is a common finding in clients with a rotator cuff injury. The rotator cuff is a group of muscles and tendons that stabilize the shoulder joint and facilitate its movement. When these muscles or tendons are injured, movements such as lifting the arm away from the body (abduction) can become painful and difficult.
Choice B reason:
Alteration in the contour of the joint is not typically associated with a rotator cuff injury. This finding is more indicative of conditions that cause changes in the bone structure, such as arthritis or dislocation.
Choice C reason:
A positive Tinel's sign is used to diagnose nerve compression or nerve damage, particularly in conditions like carpal tunnel syndrome. It is not a test used to assess rotator cuff injuries.
Choice D reason:
A negative drop arm test would suggest that the client does not have a rotator cuff injury. The drop arm test is performed by having the client lift the arm to 90 degrees and then slowly lower it. If the client can control the motion and lower the arm smoothly, the test is negative. A positive drop arm test, where the client cannot control the descent of the arm, would indicate a rotator cuff injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Babinski's sign is a neurological reflex that's tested by stroking the sole of the foot. A positive Babinski's sign, which is normal in infants but abnormal in adults, is indicated by dorsiflexion of the great toe (the toe points up) while the other toes fan out. This reflex suggests dysfunction of the corticospinal tract, which may be due to various neurological conditions. In the context of a stuporous patient with an unrepaired femur fracture, a positive Babinski's sign could indicate an acute neurological change possibly related to the injury or a secondary complication such as a fat embolism syndrome, which can occur after fractures and may affect the brain.
Choice B reason:
Pronation of the arms is not associated with Babinski's sign. Pronation is a rotational movement where the hand and upper arm are turned inwards. While arm movements are part of the neurological examination, they do not constitute a response to the plantar reflex test used to elicit Babinski's sign.
Choice C reason:
Pinpoint pupils may indicate opioid overdose or damage to the pons due to various causes, but they are not a component of Babinski's sign. Pupil size and reaction to light are important in neurological assessments, but they are separate from the reflexes tested by the Babinski sign.
Choice D reason:
Jerking contractions of the head and neck are not related to Babinski's sign. These could be indicative of seizure activity or other neurological disorders but are not a response to the plantar reflex test.
Correct Answer is A
Explanation
Choice A: Monitor the client for hypoglycemia
When a nurse administers an incorrect insulin dose, the immediate concern is the risk of hypoglycemia, especially since the insulin dose given was for a higher blood glucose level than the actual reading. Hypoglycemia can occur when blood glucose levels drop below 70 mg/dL. Symptoms of hypoglycemia include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Monitoring the client for hypoglycemia allows the nurse to detect and treat it promptly, ensuring the client’s safety.
Choice B: Complete an incident report
While completing an incident report is important for documenting the medication error and preventing future occurrences, it is not the immediate priority. The nurse’s first responsibility is to ensure the client’s safety by addressing the potential hypoglycemia. Once the client’s condition is stable, the nurse can then complete the incident report.
Choice C: Give the client 15 to 20 g of carbohydrate
Administering 15 to 20 grams of carbohydrate is a treatment for hypoglycemia. However, this action should only be taken if the client is actually experiencing hypoglycemia. The nurse should first monitor the client’s blood glucose levels to confirm hypoglycemia before administering carbohydrates.
Choice D: Notify the nurse manager
Notifying the nurse manager is important for accountability and to ensure that appropriate follow-up actions are taken. However, it is not the immediate priority. The nurse should first monitor the client for hypoglycemia and address any immediate health concerns before notifying the nurse manager.
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