A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?

Third level priority

First level priority

Routine

Second level priority

Answer and Explanation

The Correct Answer is B

A.   This category refers to non-urgent problems, which does not apply here as the client is showing signs of severe distress and requires immediate attention.
B.   Central cyanosis, a low heart rate (bradycardia), and low blood pressure are life-threatening signs that necessitate immediate intervention to stabilize the patient.
C.   This is not a routine or minor situation. The client is in critical condition and requires urgent intervention.
D.   While second-level priorities are important, this patient has life-threatening signs requiring first-level priority, immediate action, and stabilization.

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Correct Answer is D

Explanation

A. Cerebral palsy affects movement and coordination but typically presents with different types of motor impairment and not the specific signs of Parkinsonism.
B. Ataxia involves a lack of coordination, often affecting gait, but it would not typically involve the specific signs such as pill-rolling tremor or stooped posture.
C. Muscular dystrophy involves muscle weakness and atrophy but does not typically cause the motor symptoms observed in this patient.
D. Parkinson's disease is characterized by the classic signs of tremor (pill-rolling), bradykinesia (slow movement), postural instability, and a shuffling gait, which the patient exhibits.

A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 5

Correct Answer is D

Explanation

A. This grade indicates trace contraction but no movement. It is not appropriate in this case, as the patient has full range of motion.
B. Grade 2. This grade reflects full range of motion with gravity eliminated. The patient’s range of motion is against gravity, so this is not the correct grade.
C. Grade 3. This grade indicates full range of motion against gravity but without resistance. The patient is able to resist full force, so this is not the correct grade either.
D. Grade 5. This grade indicates normal strength with full range of motion against gravity and full resistance. This best describes the patient's strength, which is normal.

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A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:

Correct Answer is D

Explanation

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?

Correct Answer is D

Explanation

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