In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Instruct the client to close both eyes.

Cover the client with a warmed blanket.

Darken the client's room environment.

Measure the client's body temperature.

Answer and Explanation

The Correct Answer is A

A.   Instructing the client to close their eyes is crucial during sensory assessments, including temperature testing. This helps ensure that the client does not rely on visual cues to determine the temperature of
the stimuli, allowing the nurse to accurately assess the client’s sensory perception based purely on
touch and temperature differences.
B.   Covering the client with a warmed blanket is not necessary for assessing temperature perception. This action could alter the client’s baseline sensory perception by affecting their skin temperature, which could lead to inaccurate results. The sensory assessment requires the client to experience temperature changes directly on their skin without external influences like additional warmth.
C.   Darkening the room is not relevant for assessing temperature sensation. Visual impairment (like darkening the room) is not related to sensory nerve function related to temperature perception, and this step does not contribute to an accurate assessment of the client's ability to perceive temperature changes.
D.   Measuring the client’s body temperature is not a direct method for assessing their sensory nerve function or temperature perception. While knowing the body temperature might be relevant for other reasons, it does not directly assess how well the client can sense temperature changes on their skin.

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Correct Answer is D

Explanation

A. Diminished short-term memory in older adults can be a sign of normal aging or early cognitive decline, such as mild cognitive impairment or early-stage dementia. While this is concerning, it is not typically an immediate indicator requiring urgent medical follow-up. It is important to monitor and assess memory changes over time, but it might not necessitate immediate action unless accompanied by other significant symptoms.
B. Reduced fine motor skills can occur due to aging, arthritis, or neurological conditions such as Parkinson's disease. While this finding is important for evaluating the client's functional status and quality of life, it does not usually require immediate medical follow-up unless it is sudden, severe, or accompanied by other alarming symptoms.

C. The Babinski reflex is a neurological test where stroking the sole of the foot causes the big toe to extend. In adults, a negative Babinski reflex (where the big toe does not extend) is normal and indicates that the corticospinal tract is functioning properly. A positive Babinski reflex is abnormal in adults and may indicate neurological damage.
D. A change in awareness of surroundings is a more urgent concern. It could indicate acute cognitive changes, delirium, or severe neurological issues that require prompt evaluation. Such changes can be related to various serious conditions, including infections, metabolic imbalances, or acute brain disorders.

A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus. C. Check the pupillary response to light. D. Ask the client to open his eyes.

Correct Answer is B

Explanation

A. While notifying the healthcare provider is important if there are significant changes in the client's level of consciousness, it should not be the immediate next step. Before alerting the provider, the nurse needs to perform additional assessments to determine the extent of the client's unresponsiveness and gather more information about their neurological status.
B. Observing for eye opening in response to a painful stimulus is a critical step in assessing the depth of unconsciousness. This response helps determine the client's level of consciousness and can provide information about the severity of their condition.
C. Checking the pupillary response to light is important in evaluating neurological function and can provide information about brainstem activity and potential neurological deficits. However, it is secondary to checking for responses to stimuli like painful stimuli if the client is not opening their eyes spontaneously. Pupillary response should be assessed as part of a comprehensive neurological exam.
D. Asking the client to open his eyes might not be effective if the client is unresponsive or has impaired consciousness. If the client is not responding spontaneously, it is likely that verbal commands will also be ineffective. This step is less useful when assessing levels of consciousness compared to more objective assessments like responses to painful stimuli.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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