The nurse determines through neurologic testing that a patient has sensory and motor impairment of bilateral lower extremities. The most important reason to assess for this in the client is to:

contribute to the medical diagnosis of the client.

provide a baseline assessment against which to evaluate changes in function.

plan care to protect the client from falls/injury.

anticipate other neurologic deficits that may arise.

Answer and Explanation

The Correct Answer is C

A. Contributing to the medical diagnosis is a secondary goal for nursing care. The nurse's primary role is to ensure patient safety and prevent complications such as falls, which are more likely in patients with sensory and motor impairments.
B. While establishing a baseline for future comparison is important, it is not the most immediate concern. The nurse's priority is preventing falls and injury related to the impairment.
C. The priority in this case is to protect the client from falls or injury, as impaired motor and sensory function in the lower extremities increases the risk for accidents. Preventing injury will guide the development of the care plan, such as implementing fall precautions.
D. Anticipating other neurologic deficits is valuable but not the most urgent concern compared to protecting the client from the immediate risk of falls.

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Correct Answer is D

Explanation

A. A large cluster of pustules may indicate an infection or inflammatory process, but it is not necessarily indicative of an immediate danger compared to other options.
B. Raised, tubular, white areas may represent benign conditions, such as skin tags or cysts, which generally do not require urgent evaluation unless symptomatic.
C. Beige, small brown spots are often benign, such as liver spots or freckles; these typically do not signal immediate concern unless there are changes in size or color.
D. An irregular shaped, blue mole with white specks raises significant concern for potential melanoma, a serious form of skin cancer; any atypical characteristics in moles warrant immediate evaluation to rule out malignancy.

A. no bowel sounds noted during the assessment. B. an SPO2 which registers 90% while the client is asleep. C. increasing abdominal distention. D. a small amount of green-tinged fluid from the nasogastric tube.

Correct Answer is C

Explanation

A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.

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The nurse determines through neurologic testing that a patient has sensory and motor impairment of bilateral lower extremities. The most important reason to assess for this in the client is to:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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