A nurse is assessing a patient post-stroke for unexpected ROM findings. Which observation requires immediate intervention?
The patient performs full ROM against gravity with slight difficulty.
The patient demonstrates symmetric strength in both arms.
The patient demonstrates Grade 2 muscle strength in both legs during resistance testing.
The patient exhibits unilateral weakness with inability to perform full ROM on one leg.
The Correct Answer is D
Choice A reason: Performing full range of motion against gravity, even with slight difficulty, indicates a muscle strength grade of at least 3 to 4. This is a relatively functional outcome for a post-stroke patient and does not indicate an acute, life-threatening crisis or a sudden decline that requires immediate nursing intervention.
Choice B reason: Symmetric strength is an expected, normal finding, or at the very least, an ideal recovery goal. If a post-stroke patient demonstrates symmetry, it suggests effective rehabilitation or that the initial neurological deficit was minimal, which does not signal an acute, unexpected change in the patient's condition.
Choice C reason: Grade 2 muscle strength indicates that the patient can move their limb in a gravity-eliminated plane but cannot move against gravity. While this represents a significant motor deficit requiring ongoing physical therapy, it is a stable, expected finding in a post-stroke patient and not an acute change requiring emergency intervention.
Choice D reason: An acute, unilateral weakness or the sudden inability to perform full range of motion—especially if it is new or progressive following a stroke—is a major warning sign of neurological deterioration, such as an extension of the stroke, increased edema, or other secondary complications like a massive hematoma or herniation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Palpation of the thyroid gland is an assessment technique directed at evaluating the endocrine system, specifically looking for thyromegaly, nodules, or tenderness. It has no diagnostic relevance to the assessment of pupillary asymmetry or acute neurological dysfunction, making it an inappropriate next step in this specific context.
Choice B reason: While assessing vital signs is a fundamental component of a comprehensive nursing assessment, blood pressure measurement provides data on cardiovascular hemodynamics. It does not provide direct evidence regarding the etiology of anisocoria or focal neurological deficits related to cranial nerve integrity or intracranial pressure status.
Choice C reason: Vision acuity testing utilizing a Snellen chart evaluates the integrity of the optic nerve (cranial nerve 2). While vision changes can be secondary to neurological issues, it does not provide the immediate clinical data required to evaluate the pupillary reflex arc and direct brainstem function.
Choice D reason: Pupillary asymmetry, or anisocoria, requires immediate evaluation of cranial nerve 3 (oculomotor nerve) integrity. Assessing the pupillary response to light, including both direct and consensual reactions, is critical to differentiate between physiological anisocoria and pathological causes such as uncal herniation, intracranial hemorrhage, or other oculomotor nerve compressions.
Correct Answer is A
Explanation
Choice A reason: The mitral valve, also known as the bicuspid valve, is an atrioventricular valve located between the left atrium and the left ventricle. Its primary physiological function is to ensure unidirectional blood flow by closing tightly during ventricular systole, thereby preventing regurgitation of high-pressure blood back into the left atrium.
Choice B reason: The tricuspid valve is situated between the right atrium and the right ventricle. It functions to prevent the retrograde flow of deoxygenated blood into the right atrium during right ventricular contraction. It is anatomically positioned on the right side of the heart and does not manage left-sided pressures.
Choice C reason: The aortic valve is a semilunar valve located between the left ventricle and the aorta. Its function is to prevent blood from flowing back from the systemic circulation into the left ventricle during ventricular diastole. It does not regulate blood flow between the atrial and ventricular chambers.
Choice D reason: The pulmonary valve is a semilunar valve positioned between the right ventricle and the pulmonary artery. It serves to prevent the backflow of deoxygenated blood from the pulmonary vasculature into the right ventricle during the relaxation phase of the cardiac cycle, maintaining efficient forward flow to the lungs.
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