How should the nurse evaluate the client's motor ability and function?
Inspect muscle symmetry in the upper and lower extremities
The RN asks the client to squeeze their hand or show 2 fingers and lift their arm of the bed
Check plantar response and deep tendon-reflex testing bilaterally
Comparative cranial nerve assessments and ability to follow simple commands
The Correct Answer is B
A. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.
B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.
C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.
D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Assessment of neurologic status
While neurological assessment is important, it is not the priority in this situation. The immediate priority is managing the chest wound and airway to ensure oxygenation and prevent further complications.
B. Obtain IV access with two large bore lines and blood for lab studies
IV access is important for fluid resuscitation and medication administration but is not the immediate priority compared to securing the airway and ensuring ventilation.
C. Placement of a naso-gastric tube to decompress the stomach
Although the naso-gastric tube may be necessary to decompress the stomach later, it is not the priority in the initial management of a client with a gunshot wound to the chest.
D. Placement of an indwelling catheter (Foley) to measure urine output
While measuring urine output is important for monitoring renal function and fluid balance, it is not the priority in this emergency situation.
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.