The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?

ability to swallow pureed foods

client reports mild headache

Weakness

Glasgow coma scale of 5

Answer and Explanation

The Correct Answer is D

A.   Ability to swallow pureed foods suggests some functional capacity and is not an immediate concern requiring immediate reporting.
B.   A mild headache reported by the client might not indicate a critical issue requiring immediate reporting.
C.   Weakness can be a concerning symptom, but the severity or extent of weakness needs further clarification before urgent reporting.
D.   A Glasgow Coma Scale (GCS) score of 5 is indicative of severe impairment of consciousness, requiring immediate attention and further evaluation by the healthcare provider.

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Correct Answer is B

Explanation

A. A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B. Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C. Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D. Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.

A. Report the finding, and refer the client to a specialist for further examination. B. Tell the client that a mass was felt, but is nothing to worry about. C. Instruct the client to return for a repeat assessment in 1 month. D. Continue the examination, and document the findings on the chart.

Correct Answer is A

Explanation

A firm, irregularly shaped mass found during a rectal examination could potentially indicate a serious condition such as a tumor or other pathology. It's essential to report such findings and refer the client to a specialist for further evaluation and appropriate diagnosis.
B. It's important not to dismiss or downplay the significance of finding a mass, as it could signify a serious health issue.
C. Waiting a month for reassessment could potentially delay necessary medical intervention if the mass is concerning.
D. While documentation is important, it's crucial to prioritize immediate reporting and referral for further evaluation when such findings are discovered.

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA). Which of the following findings should the nurse report to the practitioner immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?