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. Immediate removal of the cause of obstruction.

Cardiac tamponade is a life-threatening condition caused by fluid accumulation in the pericardium, which compresses the heart. The definitive treatment is pericardiocentesis to remove the fluid and relieve the obstruction.

B. Patient will be admitted for a cardiac catheterization.

While catheterization may be performed later for underlying cardiac disease, tamponade requires urgent intervention, not just admission.

C. Administering furosemide for its diuretic effects.

Diuretics reduce preload, which can worsen hypotension in tamponade by further decreasing cardiac output.

D. Withholding IV fluids due to fluid overload.

IV fluids may be used to maintain preload while waiting for pericardiocentesis. The issue is not volume overload but rather mechanical obstruction.

A. Causative agent and duration of exposure B. Depth of burn C. Anatomical location of burns on the body D. Total Body Surface Area (TBSA) percentage E. Time of day burn occurred

Correct Answer is ["A","B","C","D"]

Explanation

A. Causative agent and duration of exposure – Chemical, electrical, or thermal burns differ in severity.

B. Depth of burn – Superficial, partial-thickness, and full-thickness burns determine severity.

C. Anatomical location – Burns over joints, face, or perineum have higher morbidity.

D. Total Body Surface Area (TBSA) percentage – Used to estimate fluid resuscitation needs (e.g., Parkland formula).

E. Time of day burn occurred – Time does not affect burn severity.

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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)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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