A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?

Choice A reason: Palpate the client’s pedal pulses

Palpating the client’s pedal pulses assesses the blood flow to the lower extremities but does not provide information about the client’s muscle strength. This action is important for evaluating circulation but is not relevant for determining strength.

Choice B reason: Ask the client how strong she feels today

Asking the client how strong she feels today provides subjective information about the client’s perception of her strength. While this can be useful, it does not offer an objective measure of muscle strength. Objective assessments are more reliable for determining the client’s actual strength.

Choice C reason: Ask the client to touch her finger to her nose

Asking the client to touch her finger to her nose assesses coordination and fine motor skills rather than muscle strength. This test is often used to evaluate neurological function but does not provide information about the strength of the muscles needed for ambulation.

Choice D reason: Ask the client to push her feet against the nurse’s palms

Asking the client to push her feet against the nurse’s palms is an effective way to assess the strength of the lower extremities. This action provides an objective measure of the client’s muscle strength, which is crucial for determining her ability to ambulate safely. This test helps the nurse evaluate whether the client has sufficient strength to stand and walk.

Choice A reason: Drive the client to the nearest emergency department

While it might seem helpful to drive the client to the nearest emergency department, it is not the best course of action. The symptoms described—right-sided weakness and slurred speech—are indicative of a possible stroke. Time is critical in stroke management, and emergency services can provide immediate medical intervention and transport to a stroke center, which is essential for the best possible outcome.

Choice B reason: Call emergency services

Calling emergency services is the most appropriate action. The client is exhibiting signs of a stroke, and rapid medical intervention is crucial. Emergency medical services (EMS) can begin treatment en route to the hospital and ensure the client is taken to a facility equipped to handle strokes. This action maximizes the chances of a positive outcome by minimizing delays in treatment.

Choice C reason: Find a location for the client to sit

Finding a location for the client to sit might provide temporary comfort, but it does not address the urgent need for medical intervention. In the case of a suspected stroke, immediate action is necessary to prevent further damage. Sitting the client down does not provide the critical care needed in this situation.

Choice D reason: Obtain the telephone number of the client’s provider

Obtaining the telephone number of the client’s provider is not the priority in an emergency situation like this. While it might be useful information later, the immediate need is to get the client to a hospital as quickly as possible. Contacting the provider can be done after emergency services have been called.