A nurse observes a client with unexpected facial muscle twitching during a head-to-toe assessment. What is the most appropriate action the nurse should take?
Document the client has this condition
Request a neurological consultation
Report the finding and complete the assessment
Perform a neurological assessment
The Correct Answer is D
Reasoning:
Unexpected muscle twitching, or fasciculations, can be a clinical indicator of underlying neurological dysfunction or electrolyte imbalances, such as hypocalcemia (Chvostek’s sign). When a nurse identifies an abnormal finding during a general screening, they must transition to a focused physical assessment to gather comprehensive data regarding the symptom's origin.
A. Documentation is a necessary step in the nursing process, but it is not the immediate "action" required when a new, unexpected finding is discovered. Simply documenting the twitching without performing a further assessment to determine its severity, location, or associated symptoms is an incomplete and potentially unsafe nursing intervention.
B. Requesting a consultation is a collaborative intervention that may be necessary later; however, the nurse must first perform a thorough assessment to provide the healthcare provider with detailed clinical data. The nurse’s primary responsibility is to define the scope of the problem through physical examination before escalating the care.
C. Reporting the finding is essential, but "completing" the general assessment without pausing to investigate an abnormal finding violates the principles of clinical prioritization. If a client exhibits a neurological sign, the nurse must prioritize a focused neurological exam to ensure there is no acute deterioration in the client’s status.
D. Performing a focused neurological assessment is the priority action. This includes evaluating cranial nerve function, assessing for other signs of neuromuscular irritability, and checking for associated symptoms like weakness or paresthesia. This step ensures the nurse has gathered sufficient objective data to identify the potential cause and urgency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Reasoning:
Benign prostatic hyperplasia involves the nonmalignant hypertrophy of the prostate gland, which leads to the mechanical compression of the prostatic urethra. This obstruction results in lower urinary tract symptoms (LUTS) as the bladder must work harder to overcome the resistance to urine outflow.
A. Complete bladder emptying is unlikely in a client symptomatic for BPH. The urethral obstruction typically leads to chronic urinary retention and significant post-void residual (PVR) urine. This residual volume contributes to the sensation of incomplete emptying and increases the risk of developing cystitis or bladder stones.
B. While BPH can cause a sensation of fullness or pressure, acute bladder pain is not a standard finding unless there is a secondary complication like a urinary tract infection or acute urinary retention. The progression of BPH symptoms is typically gradual and obstructive rather than acutely painful.
C. Although frequency occurs, the hallmark of the obstructive phase of BPH is the inability to initiate and maintain a strong stream. While "frequency with small amounts" describes the outcome, the most specific and universally reported nocturnal symptom that disrupts the quality of life in these patients is nocturia.
D. Nocturia is one of the most common and bothersome symptoms of BPH. As the bladder fails to empty fully during the day, residual volume builds up, and the bladder's functional capacity is reached more quickly at night. This necessitates multiple trips to the bathroom, significantly disrupting sleep patterns.
Correct Answer is D
Explanation
Reasoning:
Passive range of motion involves the external manipulation of joints to maintain existing flexibility and prevent structural complications. It is indicated for patients who are unable to independently move their extremities due to neurological deficit, sedation, or physical restriction to preserve synovial fluid distribution and prevent permanent joint contractures.
A. Passive range of motion does not provide the necessary mechanical loading or weight-bearing stress required to stimulate osteoblastic activity. Bone density is maintained primarily through active, weight-bearing exercises that stress the skeletal system. Without such stress, bone resorption outpaces formation regardless of passive joint movement.
B. Muscle atrophy is a physiological reduction in muscle fiber diameter resulting from a lack of active contraction. Since passive ROM does not involve the client’s voluntary motor unit recruitment or muscular work, it cannot prevent the metabolic and structural breakdown of muscle tissue associated with prolonged immobility.
C. Hypertrophy or an increase in muscle mass requires resistance training and active metabolic demand to stimulate protein synthesis within myofibrils. Passive ROM involves no active engagement of the client's musculoskeletal system; therefore, it is physiologically impossible for this intervention to result in increased muscle mass.
D. The primary therapeutic goal of passive ROM is to maintain the current flexibility of the joint and surrounding connective tissues. By moving the joint through its full available arc, the nurse helps prevent the shortening of ligaments and tendons, ensuring the joint remains functional for future use.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.