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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.
B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.
C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.
D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.
Correct Answer is B
Explanation
A. Assess for the presence of chest pain: While chest pain should always be assessed in a comprehensive health history and physical examination, it is not specifically related to multiple sclerosis unless there are concurrent cardiac issues.
B. Inquire about urinary tract problems: Urinary symptoms such as urinary urgency, frequency, hesitancy, or incontinence are common in multiple sclerosis due to neurogenic bladder dysfunction. Therefore, it is essential to inquire about these symptoms to assess the extent of neurological involvement and provide appropriate management.
C. Inspect the skin for rashes or discoloration: While skin manifestations can occur in multiple sclerosis, they are less common and not typically primary concerns during initial assessment. However, if the patient reports skin changes, they should be evaluated accordingly.
D. Ask the patient about any increase in libido: Changes in libido are not typically associated with multiple sclerosis unless they are related to psychological or emotional factors. While sexual dysfunction can occur in MS, it is not the primary focus during the initial assessment unless the patient presents with related concerns.
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