A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Reassure the client that information they share with the nurse is confidential

Instruct that complementary therapies are rarely helpful

Assess physical appearance and gait

Review current medication list including dosage & frequency

Ask about current alcohol or drug use

Answer and Explanation

Correct Answer : A,C,D,E

A. Reassure the client that information they share with the nurse is confidential
Establishing trust and confidentiality is essential in a health interview, especially for clients with neurological deficits who may feel vulnerable.

B. Instruct that complementary therapies are rarely helpful
This statement is not evidence-based and may dismiss patient preferences. Some complementary therapies, such as physical therapy or mindfulness, can be helpful in neurological conditions.

C. Assess physical appearance and gait
Observing physical appearance and gait provides important clues about neurological deficits, such as weakness, ataxia, or tremors.

D. Review current medication list including dosage & frequency
Medication history is critical in neurological assessments, as certain medications (e.g., anticoagulants, anticonvulsants) can impact the client’s condition.

E. Ask about current alcohol or drug use
Alcohol and drug use can contribute to neurological impairment and should be assessed during the history-taking process.

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Correct Answer is A

Explanation

A. Atropine 1 mg IV push

A C3 spinal cord injury disrupts sympathetic control, causing bradycardia. Atropine is the first-line treatment for symptomatic bradycardia.

B. Epinephrine 1 mg IV

Epinephrine is used for cardiac arrest, not initial management of bradycardia.

C. Adenosine 6 mg IV push

Adenosine is used for supraventricular tachycardia, not bradycardia.

D. Milrinone 50 mcg/kg IV push

Milrinone is an inotrope used in heart failure, not bradycardia.

A. is expected to be decreased for three to five days. B. will be reduced in the first 24-48 hours and will then increase. C. output will be greatest in the first 24 hours after the burn injury. D. will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.

Correct Answer is B

Explanation

A. is expected to be decreased for three to five days.
In the initial stages following severe burn injury, there is often oliguria (low urine output), but this is typically followed by diuresis (increased urine output) after the first 24-48 hours, not a decrease over 3-5 days.

B. will be reduced in the first 24-48 hours and will then increase.
In the first 24-48 hours following a severe burn injury, the body may undergo a state of hypovolemia and oliguria. As fluid resuscitation begins, urine output typically increases.

C. output will be greatest in the first 24 hours after the burn injury.
Although urine output may increase with proper fluid resuscitation, it is not usually greatest in the first 24 hours; the increase typically happens after the initial resuscitation period.

D. will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
While fluid resuscitation leads to an increase in urine output after the first 24-48 hours, it is not expected to be elevated right away. The kidneys may initially respond with oliguria.

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A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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