A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Review the client's serum electrolytes.

Evaluate client's muscle strength and hand grips.

Check distal phalanges capillary refill.

Observe skin for erythema, edema, and warmth.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Reviewing the client's serum electrolytes is incorrect. While abnormalities in electrolyte levels can sometimes contribute to neurological symptoms, such as paresthesia, reviewing the client's serum electrolytes may not directly identify additional findings consistent with the client's reported paresthesia of the hands and legs. Therefore, this option is less relevant for assessing paresthesia and identifying additional consistent findings.
Choice B Reason:
This is the correct action to identify additional findings consistent with the client's paresthesia. Paresthesia, or abnormal sensations like burning or tingling, may indicate neurological dysfunction. Assessing the client's muscle strength and hand grips can provide valuable information about neurological function and help identify any weakness or changes that may be associated with the paresthesia.
Choice C Reason:
Checking distal phalanges capillary refill is incorrect. Checking distal phalanges capillary refill is important for assessing peripheral circulation, but it may not directly identify additional findings consistent with paresthesia. While impaired circulation could contribute to sensory disturbances, such as paresthesia, it is not always the primary cause. Therefore, this option may not fully capture the sensory aspect of the client's reported symptoms.
Choice D Reason:
While observing the skin for signs of inflammation or irritation is important in assessing for other conditions, such as infection or inflammation, it is not directly related to identifying additional findings consistent with paresthesia. Paresthesia primarily involves abnormal sensations and neurological function rather than changes in the skin.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A Reason:
This option can help minimize clothing-related artifacts that may interfere with auscultation. Ensuring that the stethoscope is in direct contact with the skin allows for better transmission of sounds
Choice B Reason:
Ensuring the room is as quiet as possible is appropriate. Background noise can interfere with the clarity of auscultatory sounds. Ensuring a quiet environment helps reduce external interference and improves the nurse's ability to accurately hear and interpret the sounds.
Choice C Reason:
Keeping the examination room warm, and warm the stethoscope is appropriate. Cold temperatures can cause vasoconstriction and muscle tension, leading to increased tension in the skin and subcutaneous tissues, which may affect the quality of auscultatory sounds. Keeping the examination room warm and warming the stethoscope helps minimize this effect, ensuring clearer auscultation.
Choice D Reason:
Document the roaring and crackles is inappropriate. Documenting auscultatory findings such as roaring and crackles is important for clinical assessment and documentation but does not mitigate artifacts during auscultation. It is crucial to focus on optimizing the auscultation environment and technique to ensure accurate interpretation of sounds.
Choice E Reason:
Wetting the chest hair before auscultating is appropriate. Chest hair can create friction and produce artifacts during auscultation, particularly when using a stethoscope. Wetting the chest hair helps reduce friction and minimize artifacts, allowing for clearer auscultatory sounds.

A. Shrug shoulders against resistance. B. Stand up slowly with eyes closed. C. Turn head from side to side. D. Raise both arms overhead

Correct Answer is A

Explanation

Choice A Reason:
Shrug shoulders against resistance is correct because cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles. Instructing the client to shrug their shoulders against resistance tests the strength and function of the trapezius muscle, which is primarily innervated by cranial nerve XI. Therefore, this instruction directly assesses the function of the cranial nerve XI.
Choice B Reason:
Stand up slowly with eyes closed is incorrect because standing up slowly with eyes closed primarily assesses proprioception and balance, which involve multiple cranial nerves and the vestibular system. While cranial nerve XI may play a role in maintaining posture and balance, it is not the primary nerve involved in this assessment.
Choice C Reason:
Turn head from side to side is incorrect because turning the head from side to side primarily assesses the function of the sternocleidomastoid muscle, which is also innervated by cranial nerve XI. However, this action alone does not provide resistance against which the muscle can contract, making it less specific for assessing cranial nerve XI compared to the instruction to shrug the shoulders against resistance.
Choice D Reason:
Raise both arms overhead incorrect because raising both arms overhead primarily assesses motor function and strength of the upper extremities, which do not directly involve the muscles innervated by cranial nerve XI. While the trapezius muscle may be indirectly involved in shoulder movement, this action does not specifically target the function of cranial nerve XI.

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A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is a 35-year-old male with no history of any medical conditions is in the clinic for an annual physical. Exhibits Nurse analyzes the findings. What can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

Correct Answer is A

Explanation

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