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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F"]
Explanation
A. The correct rate is 6 mL/hr
The correct calculation should be verified.
B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K
Protamine sulfate, not vitamin K, is the antidote for heparin.
C. The nurses will complete an event report due to the medication error
A medication error must be reported.
D. Nurse A will document about the event report in the patient’s EMR
Incident reports are internal documents and should not be documented in the EMR.
E. The patient has received a dose of heparin over the prescribed amount
Due to the increased concentration, the patient received more heparin than intended.
F. The patient has received 3200 units of heparin from 1700-1900.
This calculation confirms overdosing.
Correct Answer is B
Explanation
A. White Blood Cell decrease
Platelet transfusions do not affect WBC levels. WBCs may change in response to infection or inflammation, but this is not an indicator of successful platelet transfusion.
B. Platelets increase
The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.
C. Hemoglobin increase
Hemoglobin levels increase after red blood cell (RBC) transfusions, not platelet transfusions.
D. PT and INR normalize
PT/INR measures clotting function, which is affected by clotting factors, not platelets. Platelet transfusions do not directly correct prolonged PT/INR.
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