The same patient reports that he was able to sleep through the night.
However, he notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers.
He also reports mild nausea and has no desire to eat breakfast.
There is a 3 cm by 5 cm area of blood noted on the bandage.
His left arm is warm to touch.
His left shoulder and collarbone are symmetric.
As a nurse, which findings would indicate that the patient is progressing as expected?

The patient was able to sleep through the night.

The patient’s left arm is warm to touch.

The patient’s left shoulder and collarbone are symmetric.

The patient has no desire to eat breakfast.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.

Choice B rationale

The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.

Choice C rationale

The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.

Choice D rationale

The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale

While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.

Choice B rationale

Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.

Choice C rationale

Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.

Choice D rationale

Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.

A. The left lower extremity is warm to touch. B. Bilateral pedal pulses are present and strong. C. The patient wiggles their right toes when the sole of the right foot is tickled. D. The right leg is externally rotated and shorter than the left.

Correct Answer is D

Explanation

Choice A rationale

While it’s important to assess all aspects of the patient’s condition, a warm left lower extremity does not necessarily indicate a right hip fracture. It could be related to other conditions, such as deep vein thrombosis or cellulitis.

Choice B rationale

The presence of strong bilateral pedal pulses is a positive sign and does not indicate a hip fracture. It suggests that the patient has good peripheral circulation.

Choice C rationale

The ability to wiggle the toes when the sole of the right foot is tickled does not necessarily indicate a hip fracture. This is a normal response and suggests that the patient has intact sensory and motor function in the foot.

Choice D rationale

A right leg that is externally rotated and shorter than the left is a classic sign of a hip fracture. This occurs because the fracture can cause the femoral head to tilt and rotate outward, making the leg appear shorter.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

A patient arrives at the emergency department experiencing chest pain after taking sildenafil.Based on the patient’s history, which medication should the nurse withhold?

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

Which client statement or behavior is most likely associated with their current condition?