How should the nurse evaluate the client's motor ability and function?
Inspect muscle symmetry in the upper and lower extremities
The RN asks the client to squeeze their hand or show 2 fingers and lift their arm of the bed
Check plantar response and deep tendon-reflex testing bilaterally
Comparative cranial nerve assessments and ability to follow simple commands
The Correct Answer is B
A. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.
B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.
C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.
D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Flow rate=(Total volume×Drop factor)÷ Time in minutes
= (250×15)÷120
= 31.25
Correct Answer is C
Explanation
A. Epinephrine 1 mg IV
Epinephrine is used for severe anaphylaxis. This reaction is more consistent with a mild allergic (febrile) transfusion reaction, which does not require epinephrine.
B. Acetaminophen 650 mg PO
Acetaminophen is used for febrile reactions but does not treat the allergic symptoms (itching, urticaria).
C. Diphenhydramine 50 mg IV
Diphenhydramine (Benadryl) is given to treat mild allergic transfusion reactions such as flushing, itching, and urticaria.
D. Furosemide 40 mg PO
Furosemide (Lasix) is given between blood transfusions to prevent fluid overload, not for allergic reactions.
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