To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

push the soles of the feet against the nurse's hands.

wiggle the toes of both feet at the same time.

pull both feet up at the same time to stretch the Achilles tendons.

stand up independently

Answer and Explanation

The Correct Answer is A

A.   Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B.   Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C.   Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D.   Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.

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Correct Answer is B

Explanation

A. While auscultating lung and abdominal sounds is important, it is not as urgent as checking neurological function in a head trauma patient.
B. Assessing verbal and motor responses is critical to evaluate the level of consciousness and neurological function in a patient with head trauma.
C. Monitoring daily weight is not an immediate concern for a patient with possible head trauma.
D. Monitoring intake and output is important but not the priority compared to assessing the neurological status in head trauma patients.

A. respirations gradually decreasing in rate and depth. B. rapid wheezing respirations for two or three breaths with short periods of apnea. C. a breathing pattern of dyspnea followed by a short period of apnea. D. quick shallow respirations with long periods of apnea.

Correct Answer is C

Explanation

A. Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B. Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C. Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D. Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.

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To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

Correct Answer is B

Explanation

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

Correct Answer is C

Explanation

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A nurse caring for a patient on bed rest with a history of respiratory health problems should:

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