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."

Answer and Explanation

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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Correct Answer is D

Explanation

A. The patient reports having a stiff neck: While a stiff neck may indicate meningeal irritation, which can be associated with a subarachnoid hemorrhage, it is not as immediately concerning as hypotension, which can indicate hypovolemic shock or complications such as vasospasm.

B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs): The presence of red blood cells in the cerebrospinal fluid is expected in a subarachnoid hemorrhage and is an important diagnostic finding but may not require immediate intervention.

C. The patient reports a severe and unrelenting headache: While a severe and unrelenting headache is a common symptom of subarachnoid hemorrhage, it is not as urgent as addressing hypotension, which can indicate hemodynamic instability and compromise perfusion to vital organs.

D. The patient's blood pressure (BP) is 90/50 mm Hg: Hypotension in a patient with a subarachnoid hemorrhage can indicate hypovolemic shock, vasospasm, or other complications. It is important to communicate this finding promptly to the healthcare provider for further
evaluation and management.

A. Observe the client's ability to smile and frown. B. Instruct the client to look up and down without moving his head. C. Ask the client to shrug his shoulders against passive resistance. D. Have the client stand with eyes his closed and touch his nose.

Correct Answer is B

Explanation

A. Observe the client's ability to smile and frown: This assessment is related to cranial nerve VII (facial nerve), which controls facial expressions.
B. Instruct the client to look up and down without moving his head: Cranial nerve III (oculomotor nerve) controls eye movements, including upward and downward gaze. Asking the client to look up and down without moving the head assesses the function of this nerve.

C. Ask the client to shrug his shoulders against passive resistance: This assessment is related to cranial nerve XI (accessory nerve), which innervates the trapezius and sternocleidomastoid muscles involved in shoulder shrugging.

D. Have the client stand with eyes his closed and touch his nose: This assessment is part of the cerebellar function test and assesses coordination and proprioception but does not specifically assess cranial nerve III.

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A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

Correct Answer is D

Explanation

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Correct Answer is B

Explanation

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