A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action?
The patient reports chronic severe back pain.
The patient expresses anxiety about having surgery.
The patient has new-onset weakness of both legs.
The patient starts to cry and says, "I feel hopeless."
The Correct Answer is C
A. The patient reports chronic severe back pain: Chronic severe back pain may indicate underlying spinal issues but does not necessarily require immediate action compared to acute symptoms such as new-onset weakness of both legs.
B. The patient expresses anxiety about having surgery: While addressing the patient's anxiety is important for providing holistic care, it is not the most immediate concern compared to new- onset weakness of both legs, which may indicate spinal cord compression requiring urgent
intervention.
C. The patient has new-onset weakness of both legs: New-onset weakness of both legs suggests potential spinal cord compression or neurological deficit requiring immediate evaluation and intervention to prevent further neurological damage or complications.
D. The patient starts to cry and says, "I feel hopeless": While addressing the patient's emotional needs is important, it is not the most immediate concern compared to addressing acute neurological symptoms such as new-onset weakness of both legs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You may be able to prevent Bell's palsy by doing facial exercises regularly." Regular facial exercises have not been proven to prevent Bell's palsy. In fact, excessive facial exercises could potentially exacerbate symptoms in some cases.
B. "Medications to treat Bell's palsy work only if started before paralysis onset." While early treatment with antiviral medications may be beneficial in some cases, it is not accurate to say that medications only work if started before paralysis onset. Treatment can still be effective even after the onset of symptoms, although it may not be as effective as when started early.
C. "Call the doctor if you experience pain or develop herpes lesions near the ear." This is important information because Bell's palsy has been associated with reactivation of the herpes simplex virus. Pain or the development of herpes lesions near the ear could indicate impending or active Bell's palsy, and prompt medical evaluation is necessary.
D. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." While antiviral medications can reduce the risk of herpes simplex virus reactivation, there is no guarantee that prophylactic treatment will prevent Bell's palsy. However, prompt treatment of herpes outbreaks may help reduce the risk.
Correct Answer is B
Explanation
A. Nuchal rigidity is a sign of meningitis but not specifically indicative of increased ICP.
B. Restlessness can be a sign of increased ICP due to reduced cerebral perfusion.
C. Photophobia is a common symptom of meningitis but does not directly indicate increased ICP.
D. Positive Kernig's sign is another indicator of meningitis but, like nuchal rigidity, it is not specific to increased ICP.
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