A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Reassure the client that information they share with the nurse is confidential

Instruct that complementary therapies are rarely helpful

Assess physical appearance and gait

Review current medication list including dosage & frequency

Ask about current alcohol or drug use

Answer and Explanation

Correct Answer : A,C,D,E

A. Reassure the client that information they share with the nurse is confidential
Establishing trust and confidentiality is essential in a health interview, especially for clients with neurological deficits who may feel vulnerable.

B. Instruct that complementary therapies are rarely helpful
This statement is not evidence-based and may dismiss patient preferences. Some complementary therapies, such as physical therapy or mindfulness, can be helpful in neurological conditions.

C. Assess physical appearance and gait
Observing physical appearance and gait provides important clues about neurological deficits, such as weakness, ataxia, or tremors.

D. Review current medication list including dosage & frequency
Medication history is critical in neurological assessments, as certain medications (e.g., anticoagulants, anticonvulsants) can impact the client’s condition.

E. Ask about current alcohol or drug use
Alcohol and drug use can contribute to neurological impairment and should be assessed during the history-taking process.

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Correct Answer is C

Explanation

A. Deep purple erythema

This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.

B. Facial nerve deficits

This indicates nerve injury, which is serious but may not be immediately life-threatening.

C. Dysphonia or dysphagia

Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.

D. Heart rate of 100 and blood pressure of 96/68

These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.

A. includes the head-to-toe anterior and posterior assessment. B. priorities are continuing and ongoing but treatment will be deferred if the clients unstables C. is focused on airway maintenance and ventilation effectiveness. D. focuses on the ABCDs of the client to identify life threatening problems

Correct Answer is D

Explanation

A. includes the head-to-toe anterior and posterior assessment.
This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.

B. priorities are continuing and ongoing but treatment will be deferred if the client is unstable.
In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.

C. is focused on airway maintenance and ventilation effectiveness.
As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.

D. focuses on the ABCDs of the client to identify life-threatening problems.
The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).

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A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Nursing Test Bank

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