Patient Data

Exhibits

As a result of the Adult Protective Services investigation, additional care has been established for the client including physical and occupational therapy twice weekly and a home health aide to provide assistance with activities of daily living.

Drag from statement options to complete the sentence.

To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Rationale for Correct Choices

Quality of life: Quality of life encompasses the client’s emotional well-being, ability to engage in meaningful activities, and overall life satisfaction. Since the client expressed distress over social isolation and being restricted from activities she previously enjoyed, assessing this domain is essential to determine the impact of the intervention.
Functional improvement: The client previously reported being active and independent. Monitoring progress in strength, mobility, and independence in ADLs—especially with the addition of physical and occupational therapy—is crucial for measuring the effectiveness of care and promoting client autonomy.

Rationale for Incorrect Choices

Financial security: There are no concerns or reports related to the client’s access to funds, misuse of money, or financial stress. The care plan and outcomes are not centered around her financial state.
Cognitive status: Although the client has early-stage dementia, she is currently alert, oriented, and capable of participating in discussions. The interventions aim to improve physical function and well-being rather than targeting cognitive decline at this stage.
Psychological assessment: The scenario does not describe symptoms of depression, anxiety, or emotional distress requiring formal psychological evaluation. The focus is more on restoring physical function and improving day-to-day satisfaction.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Rationale for correct Choices:

Noticeable facial droop: Facial drooping is a hallmark sign of a stroke. Early recognition is critical because prompt intervention, such as thrombolytic therapy, must occur within a narrow time window to prevent long-term neurological damage.
Garbled speech: Slurred or incomprehensible speech (dysarthria or aphasia) is another acute stroke symptom. It indicates potential involvement of the brain's language centers and requires immediate neuroimaging and evaluation.
Speech became difficult to understand: A sudden change in speech pattern strongly suggests an evolving neurologic event such as a transient ischemic attack (TIA) or stroke. Timely identification of symptom onset is essential for determining eligibility for time-sensitive stroke treatments like alteplase.

Rationale for Incorrect Choices:

Few drinks at a local seafood restaurant: While alcohol can cause slurred speech and sea food can result in allergic reaction, the patient reports with symptoms suggestive of a stroke, therefore this is not part of the immediate concerns.

A. Duration of sensation. B. Precipitous activiity. C. Time of last analgesic. D. Gait coordination.

Correct Answer is A

Explanation

Rationale:
A. Duration of sensation: This helps to determine if the symptoms are acute, intermittent, or continuous, which can provide clues about the severity of nerve compression or irritation. Changes in duration, frequency, or intensity can indicate worsening nerve impingement or the development of a new neurological deficit requiring immediate attention.

B. Precipitous activity: While it's useful to know what activity triggered the symptoms, this is secondary to understanding the timeline and progression of neurological signs, which carry more urgency.

C. Time of last analgesic: Pain control is important, but the priority is evaluating potential nerve compromise. Numbness and tingling may reflect compression or damage that cannot be addressed by analgesia alone.

D. Gait coordination: Assessing gait coordination is important to evaluate the functional impact of the neurological symptoms, which could indicate more severe nerve compression affecting motor pathways. However, it is an assessment of a motor function. The client is describing sensory symptoms.

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Focused Assessment Area	Clinical Finding
Musculoskeletal	Ambulates with a walker Flaccidity of left arm Passive range of motion of the left leg
Psychosocial	Fits of laughter Angry outbursts Tearful sharing of stories
Neurological	Drinks with repetitive cough Decorticate posturing Speaks in short sentences

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D"]

Explanation

A female client with degenerative disc disease and chronic sciatica is describing numbness and tingling down her left leg. Which assessment should the nurse obtain first?

Correct Answer is A

Explanation

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provide?

The healthcare provider prescribes 1 liter of lactate Ringer's to infuse in 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use when developing the client's plan of care?

The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

Exhibits Nurse reviews updated chart data. For each intervention, click to indicate if it is indicated or contraindicated. Each row must have only one response option selected.