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 C

Explanation

A. 63% TBSA
This value is too high based on the Rule of Nines calculation.

B. 45% TBSA
This overestimates the burn area.

C. 36% TBSA
Using the Rule of Nines, the TBSA is calculated as follows:

Entire right arm (anterior + posterior): 9%
Posterior trunk: 18%
Posterior right leg: 9%
Total TBSA = 9% + 18% + 9% = 36%

D. 27% TBSA
This underestimates the affected areas.

A. Massive blood loss leading to decreased oxygen delivery to tissues B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation

Correct Answer is C

Explanation

A. Massive blood loss leading to decreased oxygen delivery to tissues

This describes hypovolemic shock, which occurs due to significant blood or fluid loss (e.g., hemorrhage, severe dehydration). In this scenario, there is no evidence of massive blood loss, making hypovolemic shock unlikely.

B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability

This describes anaphylactic shock, which results from an acute allergic reaction (e.g., to food, medication, insect stings). There is no mention of an allergen exposure or symptoms like wheezing, stridor, or urticaria, making anaphylactic shock unlikely.

C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion

This patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.

D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation

This describes cardiogenic shock, which occurs due to heart failure (e.g., from myocardial infarction, cardiomyopathy). It leads to low cardiac output, pulmonary congestion, and organ hypoperfusion. This patient’s infection and systemic inflammation suggest septic shock, not a primary cardiac event.

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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

The nurse is caring for an adult with a burn injury. The following parts of the patient's body were burned: anterior and posterior right arm, posterior trunk. and posterior right leg. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) percentage that is involved.

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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