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 A

Explanation

A. Atropine 1 mg IV push

A C3 spinal cord injury disrupts sympathetic control, causing bradycardia. Atropine is the first-line treatment for symptomatic bradycardia.

B. Epinephrine 1 mg IV

Epinephrine is used for cardiac arrest, not initial management of bradycardia.

C. Adenosine 6 mg IV push

Adenosine is used for supraventricular tachycardia, not bradycardia.

D. Milrinone 50 mcg/kg IV push

Milrinone is an inotrope used in heart failure, not bradycardia.

A. monitoring for dysrhythmias B. monitoring for bleeding. C. adherence to their antihypertensive drugs D. preventing thrombus formation.

Correct Answer is C

Explanation

A. Monitoring for dysrhythmias
While cardiovascular health is important, dysrhythmias are not a primary concern in a small abdominal aortic aneurysm.

B. Monitoring for bleeding
While aneurysms can rupture, a small aneurysm is managed medically with blood pressure control, making bleeding less of an immediate concern.

C. Adherence to their antihypertensive drugs
Hypertension increases pressure on the aneurysm, increasing the risk of expansion and rupture. Strict adherence to antihypertensive medications is essential for preventing complications.

D. Preventing thrombus formation
While thrombus formation can occur in large aneurysms, it is not the primary focus in a small, medically managed aneurysm.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a spinal cord injury at C3. The nurse notices on the cardiac monitor a heart rate of 30 beats per minute & upon assessment of the patient, a change in mental status. What medication does the nurse anticipate will be ordered by the physician STAT?

Correct Answer is A

Explanation

The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

Correct Answer is C

Explanation

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