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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. White Blood Cell decrease
Platelet transfusions do not affect WBC levels. WBCs may change in response to infection or inflammation, but this is not an indicator of successful platelet transfusion.

B. Platelets increase
The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.

C. Hemoglobin increase
Hemoglobin levels increase after red blood cell (RBC) transfusions, not platelet transfusions.

D. PT and INR normalize
PT/INR measures clotting function, which is affected by clotting factors, not platelets. Platelet transfusions do not directly correct prolonged PT/INR.

A. Performing a mini mental status exam at admission and discharge B. Performing serial Glasgow Coma Scale exams during hospitalization C. Assessing pupils for reactivity, equality, symmetry and accommodation D. Obtaining vital signs every four hours while hospitalized

Correct Answer is B

Explanation

A. Mini mental status exam at admission and discharge

Useful for cognitive function but not for acute changes.

B. Performing serial Glasgow Coma Scale exams

The GCS is the best tool for tracking changes in neurologic status over time.

C. Assessing pupils for reactivity, equality, symmetry, and accommodation

Important but not comprehensive.

D. Obtaining vital signs every four hours

Useful but does not specifically assess neurologic function.

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How should the nurse evaluate the client's motor ability and function?

Nursing Test Bank

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