A nurse is caring for a client at an outpatient clinic.
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Nurses' Notes
3 months ago:
Middle-aged client reports experiencing fatigue for longer than 4 months.
Reports struggling to remember things and feeling depressed. Intermittent hand tremors reported and sudden episodes of leg weakness during ambulation, causing a loss of balance and gait changes. Intermittent episodes of muscle spasms started about a month ago. Reports no falls. Average work week is 40 hr in their family-owned business but has had to reduce work to 20 hr a week during "episodes" lasting about 4 days when manifestations worsen significantly. These episodes occur about once a month.
Client has 20/20 vision, but reports experiencing double vision "a couple of times." Last bowel movement was 1 day ago. Voids without difficulty but reports a feeling of "squeezing or spasm" in the genitourinary area that has only occurred a few times. No blood noted in urine.
Height 162.6 cm (64 in)
Weight 77.6 kg (171.1 lb)
BMI 29.3
Vital Signs
3 months ago:
Temperature 36.7° C (98.1° F)
Heart rate 84/min
Respiratory rate 16/min
Blood pressure 124/82 mm Hg
Oxygen saturation 97% on room air
Middle-aged client reports experiencing fatigue for longer than 4 months
Reports struggling to remember things and feeling depressed
Intermittent hand tremors reported and sudden episodes of leg weakness during ambulation, causing a loss of balance and gait changes
Intermittent episodes of muscle spasms started about a month ago
Client has 20/20 vision, but reports experiencing double vision "a couple of times."
reports a feeling of "squeezing or spasm" in the genitourinary area that has only occurred a few times
Temperature 36.7° C (98.1° F)
Heart rate 84/min
Oxygen saturation 97% on room air
Last bowel movement was 1 day ago
The Correct Answer is ["A","B","C","D","E","F"]
Rationale for correct choices
• Fatigue lasting longer than 4 months: Persistent fatigue can indicate an underlying chronic condition, autoimmune disorder, or neurological disease. Because it has lasted longer than several months, it warrants further assessment to rule out systemic or neurological causes. Chronic fatigue can significantly impair quality of life and functional capacity.
• Struggling to remember things and feeling depressed: Cognitive changes and mood disturbances may reflect neurological involvement, medication side effects, or comorbid depression. Memory issues combined with fatigue and mood changes require follow-up to assess for conditions affecting the central nervous system or systemic illness.
• Intermittent hand tremors: Hand tremors can indicate neurological disorders such as myasthenia gravis, Parkinsonism, or other neuromuscular conditions. Intermittent tremors, especially alongside muscle weakness and visual disturbances, warrant evaluation to determine the underlying etiology.
• Sudden episodes of leg weakness causing loss of balance and gait changes: Episodes of acute limb weakness with balance problems indicate potential neuromuscular dysfunction or demyelinating disease. These transient episodes impair safety and functional mobility, requiring further neurological evaluation to prevent injury.
• Intermittent muscle spasms: Muscle spasms are concerning when combined with other neuromuscular symptoms. They may indicate electrolyte imbalance, neuromuscular junction disorders, or early signs of autoimmune or neurological disease. Tracking frequency and triggers helps guide diagnosis.
• Occasional double vision: Intermittent diplopia may indicate cranial nerve involvement or neuromuscular junction pathology, such as myasthenia gravis. Even if infrequent, visual disturbances in combination with muscle weakness are red flags requiring neurological assessment.
• Genitourinary spasms: Spasms in the urinary tract may reflect neurological involvement or early autonomic dysfunction. Although infrequent, these symptoms can signal progression of a neuromuscular condition affecting bladder control and require follow-up to prevent complications.
Rationale for Incorrect findings
• Vital signs within normal limits: Temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation are all within normal ranges and do not currently indicate acute illness. No immediate intervention is required based on these values.
• Last bowel movement 1 day ago: Having a bowel movement within the last 24 hours is normal and does not indicate constipation or gastrointestinal dysfunction. No immediate follow-up is needed for bowel habits at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Denial: Denial is an expected initial stage of grief in response to terminal illness. Clients may have difficulty accepting the diagnosis and may refuse to believe the reality of their condition as a coping mechanism.
B. Reorganization: Reorganization is a later stage of grief associated with adapting to loss after bereavement. It is not typically part of the immediate response to a terminal diagnosis in the dying process.
C. Numbing: Numbing is more commonly associated with acute grief reactions following sudden loss, rather than the anticipatory grief experienced after a terminal diagnosis.
D. Reinvesting: Reinvesting refers to redirecting emotional energy into new relationships or activities after loss. This stage occurs after bereavement and is not part of the expected stages of grief during the dying process.
Correct Answer is C
Explanation
A. Observe the client's ability to keep their elbows extended when using the crutches: The elbows should be slightly flexed, not fully extended, when using crutches. Observing for elbow extension is incorrect and could indicate improper technique. Proper elbow positioning is assessed as part of gait evaluation rather than as a standalone measure.
B. Instruct the client to lean forward when using the crutches: Leaning forward places excessive pressure on the axillae and increases the risk of nerve injury. Clients should maintain an upright posture while using crutches, so this instruction is unsafe and should not be included in care planning.
C. Observe the client's gait pattern when using the crutches: Observing the gait pattern allows the nurse to assess how the client distributes weight, coordinates movements, and uses the crutches safely. This assessment is essential prior to planning care and interventions, ensuring that the client can ambulate safely and independently.
D. Ensure the client's weight is placed on their axilla area when using the crutches: Weight should be supported by the hands and arms, not the axillae, to prevent nerve damage. Ensuring proper weight distribution is part of teaching and assessment, but placing weight on the axillae is incorrect and unsafe.
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