The nurse determines through neurologic testing that a patient has sensory and motor impairment of bilateral lower extremities. The most important reason to assess for this in the client is to:
contribute to the medical diagnosis of the client.
provide a baseline assessment against which to evaluate changes in function.
plan care to protect the client from falls/injury.
anticipate other neurologic deficits that may arise.
The Correct Answer is C
A. Contributing to the medical diagnosis is a secondary goal for nursing care. The nurse's primary role is to ensure patient safety and prevent complications such as falls, which are more likely in patients with sensory and motor impairments.
B. While establishing a baseline for future comparison is important, it is not the most immediate concern. The nurse's priority is preventing falls and injury related to the impairment.
C. The priority in this case is to protect the client from falls or injury, as impaired motor and sensory function in the lower extremities increases the risk for accidents. Preventing injury will guide the development of the care plan, such as implementing fall precautions.
D. Anticipating other neurologic deficits is valuable but not the most urgent concern compared to protecting the client from the immediate risk of falls.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Magnesium at 2.0 mEq/L is within the normal range (1.6-2.2 mg/dL) and does not require immediate intervention.
B. A serum sodium level of 126 mEq/L indicates hyponatremia, which can lead to neurological complications, particularly in patients with brain cancer. Immediate reporting is necessary to manage potential risks such as seizures or altered mental status.
C. A potassium level of 3.5 mEq/L is on the lower limit of normal (3.5-5.3 mEq/L) but is still considered acceptable and does not require urgent action.
D. Calcium at 10 mg/L is an incorrect unit for this context, as total serum calcium is typically measured in mg/dL, and 10 mg/dL falls within the normal range (8.2-10.2 mg/dL).
Correct Answer is A
Explanation
A. Stage IV pancreatic cancer often leads to bile duct obstruction, causing decreased bile flow into the intestines. This results in clay-colored stools due to the absence of bile pigments.
B. Hematuria, or blood in the urine, is not a common symptom of pancreatic cancer, even in advanced stages. It is more associated with conditions affecting the urinary system.
C. Jaundice causes dark, concentrated urine rather than pale, dilute urine due to the accumulation of bilirubin in the bloodstream, which is excreted through the kidneys.
D. Weight loss, rather than weight gain, is a common manifestation in clients with advanced pancreatic cancer due to malabsorption and cachexia.
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