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 A
Explanation
Choice A reason: The liver is a large, solid organ primarily situated in the right upper quadrant (RUQ) of the abdomen, extending just under the right costal margin. Its location makes it a primary structure to assess during abdominal palpation and percussion in that specific quadrant.
Choice B reason: The stomach is primarily located in the left upper quadrant (LUQ). While parts of the stomach can extend toward the midline, it is clinically categorized as a LUQ organ and is the focus of assessment when a patient reports epigastric or left-sided discomfort.
Choice C reason: The small intestine is a lengthy organ that spans multiple abdominal quadrants, including the central (umbilical) region, the LUQ, and the RLQ. Because it is distributed throughout the abdomen, it is not considered an organ localized specifically to the right upper quadrant.
Choice D reason: The pancreas is primarily located in the epigastric region, with its head resting in the curve of the duodenum and its tail extending toward the left upper quadrant. It is centrally positioned and not considered a structure that is primarily or exclusively located within the right upper quadrant.
Correct Answer is D
Explanation
Choice A reason: While a foreign body can cause airway obstruction and localized wheezing, it is not the physiological explanation for the diffuse airway changes seen in pneumonia. Pneumonia involves generalized inflammation, whereas foreign body obstruction is typically sudden and localized to a specific bronchial branch.
Choice B reason: While fluid in the alveoli is a hallmark of pneumonia and leads to impaired gas exchange, this physiological process is more directly related to the finding of crackles (rales) due to the air moving through fluid-filled spaces rather than the wheezing associated with bronchial narrowing.
Choice C reason: Increased surface tension in alveoli is characteristic of respiratory distress syndrome (RDS) due to a surfactant deficiency. While it prevents full expansion and causes respiratory distress, it does not typically manifest as wheezing, which is a sound produced by the high-velocity movement of air through constricted airways.
Choice D reason: In pediatric pneumonia, the inflammatory response often leads to significant mucosal edema, cellular infiltration, and the production of viscous secretions within the bronchioles. This narrowing of the airway lumen increases resistance to airflow, causing the turbulence heard as wheezing, and forces the use of accessory muscles, resulting in retractions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today