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 B

Explanation

A. Measuring abdominal girth may be relevant for assessing potential complications like abdominal distention, but it is not the immediate priority in response to serosanguinous drainage from the nasogastric tube.
B. Continuing to monitor the drainage is appropriate, as serosanguinous fluid is common immediately after surgery and may gradually change as healing progresses. Monitoring allows for the identification of any changes that may require further intervention.
C. Notifying the physician may be necessary if the drainage increases or changes significantly, but immediate action is to observe and assess the drainage trend.
D. Irrigating the nasogastric tube is not warranted unless there is an obstruction or significant change in the drainage; it should only be done based on specific orders or protocols.

A. to continue the antiepileptic drug to prevent seizure activity B. morphine will be administered post-op for adequate pain control C. to continue taking the daily Aspirin until the day of surgery D. to continue the use of alternative or complementary therapies with family approval

Correct Answer is A

Explanation

A. Continuing antiepileptic drugs is crucial in patients with brain tumors, as these medications help prevent seizure activity, which is a common complication associated with brain tumors and surgical procedures.
B. While pain control is important, the specific medications used for postoperative pain management are determined after surgery; patients should be informed about general pain management strategies rather than specific drug administration.
C. Aspirin, an anticoagulant, should typically be stopped before surgery to reduce the risk of bleeding complications; therefore, patients should not continue taking it unless specifically directed by their healthcare provider.
D. Patients are usually advised to discontinue alternative or complementary therapies before surgery due to potential interactions with anesthesia or surgical procedures, and it should be clarified with the healthcare provider before proceeding.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes serosanguinous drainage from the nasogastric tube in the immediate postoperative period of a client who had a gastrectomy for gastric cancer. Which nursing action is appropriate?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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