A female client with degenerative disc disease and chronic sciatica is describing numbness and tingling down her left leg. Which assessment should the nurse obtain first?
Duration of sensation.
Precipitous activiity.
Time of last analgesic.
Gait coordination.
The Correct Answer is A
Rationale:
A. Duration of sensation: This helps to determine if the symptoms are acute, intermittent, or continuous, which can provide clues about the severity of nerve compression or irritation. Changes in duration, frequency, or intensity can indicate worsening nerve impingement or the development of a new neurological deficit requiring immediate attention.
B. Precipitous activity: While it's useful to know what activity triggered the symptoms, this is secondary to understanding the timeline and progression of neurological signs, which carry more urgency.
C. Time of last analgesic: Pain control is important, but the priority is evaluating potential nerve compromise. Numbness and tingling may reflect compression or damage that cannot be addressed by analgesia alone.
D. Gait coordination: Assessing gait coordination is important to evaluate the functional impact of the neurological symptoms, which could indicate more severe nerve compression affecting motor pathways. However, it is an assessment of a motor function. The client is describing sensory symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Arrange an appointment with a pain specialist: A pain specialist can provide comprehensive strategies for managing chronic pain related to fibromyalgia. This includes pharmacologic and non-pharmacologic options tailored to the client's needs.
B. Form an interdisciplinary team for evaluation: While helpful in complex cases, a full team may not be necessary as the first step. It may delay direct pain management support that a pain specialist could initiate more quickly. Interdisciplinary care may follow specialist input.
C. Contact a hospice nurse for an evaluation: Hospice care is intended for clients with terminal illnesses and a life expectancy of six months or less. Fibromyalgia is a chronic, non-fatal condition, so this request indicates a need for pain support, not end-of-life care.
D. Ask for a consultation with a psychologist: A psychologist can help address emotional responses to chronic pain, but cannot directly manage physical symptoms. This should be a supportive measure after physical pain is addressed by a medical pain expert.
Correct Answer is B
Explanation
Rationale:
A. Place a foam surface on top of the mattress: A foam surface may help reduce pressure, but for a stage IV pressure injury with eschar, this alone is insufficient. More advanced pressure redistribution systems are needed for adequate management of severe wounds.
B. Raise the head of the bed only to 30 degrees: Limiting the head-of-bed elevation helps reduce shear forces, which worsen pressure injuries, especially over the sacrum. This intervention is critical for preventing further tissue damage and promoting healing of deep wounds with eschar.
C. Perform passive range of motion exercises: While passive ROM supports circulation and prevents contractures, it does not directly address pressure relief or eschar management. It's beneficial, but not the top priority for treating a stage IV ulcer.
D. Increase the daily intake of vitamin C: Vitamin C supports collagen synthesis and immune function, aiding wound healing. However, nutrition alone cannot address mechanical factors like pressure and shear, which are primary contributors to pressure injury progression.
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