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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Requesting a prescription to culture the wound is the priority action because the presence of redness, warmth, and serosanguinous drainage could indicate an infection that needs to be confirmed and treated appropriately.
B. While antibiotics may be necessary if an infection is confirmed, it is crucial to first determine the presence of infection through culturing the wound.
C. Assuring the client that these findings are normal may delay necessary intervention if an infection is present, which could worsen the client's condition.
D. Cleaning the wound with sterile normal saline may be appropriate as part of wound care, but it does not address the underlying concern of possible infection and would not be prioritized over obtaining a culture.

A. Large cluster of pustules in the right axilla B. Raised, tubular, white areas on the arms C. Beige, small brown spots on the backs of both hands D. Irregular shaped, blue mole with white specks on lower leg

Correct Answer is D

Explanation

A. A large cluster of pustules may indicate an infection or inflammatory process, but it is not necessarily indicative of an immediate danger compared to other options.
B. Raised, tubular, white areas may represent benign conditions, such as skin tags or cysts, which generally do not require urgent evaluation unless symptomatic.
C. Beige, small brown spots are often benign, such as liver spots or freckles; these typically do not signal immediate concern unless there are changes in size or color.
D. An irregular shaped, blue mole with white specks raises significant concern for potential melanoma, a serious form of skin cancer; any atypical characteristics in moles warrant immediate evaluation to rule out malignancy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?

Correct Answer is A

Explanation

A client has numerous skin lesions. Which one will the nurse evaluate first?

Correct Answer is D

Explanation

While performing a neurologic assessment of the older adult patient, the nurse needs to consider which age-related changes?

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:

The nurse is providing discharge teaching for a client who has received their first external radiation treatment. The client is scheduled for daily treatments for the next 6 weeks. The nurse would include which instruction in the teaching?

The nurse teaches a diabetic client how to perform foot care. Which action by the client would indicate that they can correctly perform foot care?

Which of the following interventions would the nurse emphasize during education to assist the patient diagnosed with trigeminal neuralgia in managing their pain?

The nurse is planning care that would decrease the risk for infection in a client who is recovering from a colectomy. The nurse would include which intervention(s)? (SELECT ALL THAT APPLY)

The nurse is performing discharge planning for a client newly diagnosed with type 1 diabetes mellitus. It would be most important for the plan to include: