A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is reporting pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first?

Complete a mental status exam.

Obtain a blood alcohol level.

Inspect legs for infection or trauma.

Inquire about dietary salt intake.

Answer and Explanation

The Correct Answer is C

A.   The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B.   Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C.   This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D.   While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

Nursing Test Bank

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Correct Answer is C

Explanation

A. An absent or sluggish deep tendon reflex typically indicates a lower motor neuron lesion, which affects the peripheral nerves or spinal cord segments involved in reflex arc processing. Lower motor neuron lesions often result in reduced or absent reflexes, not brisk responses.
B. Flaccid paralysis is characterized by a lack of muscle tone and reflexes, which is usually associated with lower motor neuron damage. A brisk 4+ reflex response does not indicate flaccid paralysis but rather heightened reflex activity.
C. A brisk 4+ response indicates hyperactivity of the deep tendon reflexes, which is consistent with an upper motor neuron disorder. Upper motor neuron lesions, such as those resulting from a cerebrovascular accident (CVA), often lead to increased reflex responses due to disruption in the normal inhibitory signals from the brain.
D. A normal reflex response is typically classified as 2+ on a scale of 0 to 4, where 2+ is considered average or expected. A 4+ response indicates hyperactivity, which is not normal but rather indicates increased reflexes, usually associated with upper motor neuron issues.

A. "Can you recall the date the Twin Towers in New York were destroyed?" B. "What is the difference between a hamster and a rabbit as a pet?" C. "Should someone who lives in a glass house throw stones?" D. "Do you write checks if you know the bank account is overdrawn?"

Correct Answer is C

Explanation

A. This question assesses a client's recent memory, not their judgment.
B. This question assesses a client's knowledge and understanding of animals, not their judgment.
C. This question evaluates a client's judgment by assessing their ability to make sound decisions based on hypothetical situations. It requires the client to consider potential consequences and make a logical inference.
D. This question assesses a client's financial knowledge and decision-making skills, but it doesn't directly evaluate their judgment in a hypothetical situation.

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Naxlex Comprehensive Predictor Exams

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

Correct Answer is C

Explanation

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

Correct Answer is C

Explanation

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

To assess for muscle atrophy in the legs, which action should the nurse take?

When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?