A nurse is caring for a client who has degenerative disc disease.
Which of the following assessment findings should the nurse understand might develop with this condition? (Select All that Apply)
Hyponatremia
Paresthesia
Foot drop
Intermittent pain
Hyperreflexia
Correct Answer : B,C,D
Choice A rationale
Hyponatremia, or low sodium levels, is not typically a symptom of degenerative disc disease. It can be caused by a variety of conditions, but it is not directly linked to degenerative disc disease.
Choice B rationale
Paresthesia, or abnormal sensations such as tingling or prickling, can develop with degenerative disc disease. This is due to the fact that degenerative changes can lead to nerve compression, which can cause these sensations.
Choice C rationale
Foot drop, a gait abnormality, can be a symptom of degenerative disc disease. It can occur if the disease process affects the nerves that control the muscles involved in lifting the foot.
Choice D rationale
Intermittent pain is a common symptom of degenerative disc disease. The pain can vary in intensity and may be worse with certain activities or positions.
Choice E rationale
Hyperreflexia, or overactive reflexes, is not typically a symptom of degenerative disc disease. It is more commonly associated with conditions that affect the upper motor neurons.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Maintaining systolic BP between 141 and 145 mm Hg is considered high and can increase the risk of stroke.
Choice B rationale
The client should maintain systolic BP between 120 and 129 mm Hg. This is considered a normal blood pressure range and can help reduce the risk of stroke.
Choice C rationale
Maintaining systolic BP between 130 and 135 mm Hg is considered elevated and can increase the risk of stroke.
Choice D rationale
Maintaining systolic BP between 136 and 140 mm Hg is considered high and can increase the risk of stroke.
Correct Answer is B
Explanation
Choice A rationale
Swelling of the optic nerve, also known as papilledema, can be a sign of increased intracranial pressure (ICP). However, it is not a direct indicator of a worsening neurological condition.
Choice B rationale
The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient’s level of consciousness and neurological functioning. A decreasing GCS score indicates a worsening neurological condition, which could be due to increasing ICP12. Therefore, a decreasing GCS score is a direct indicator of a worsening neurological condition.
Choice C rationale
A blood pressure of 108/76 mm Hg is within the normal range and does not directly indicate a worsening neurological condition. However, drastic changes in blood pressure could potentially indicate a problem.
Choice D rationale
Changes in pupil size and shape can be a sign of increased ICP, but these changes are not specific to a worsening neurological condition. They could be due to various factors, including medication effects or damage to the cranial nerves.
Choice E rationale
A respiratory rate of 12/min is within the normal range for adults. Changes in respiratory patterns could potentially indicate a worsening neurological condition, but a rate of 12/min does not directly indicate this.
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