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 ["A","B","D","E"]

Explanation

A. Pain control options should be appropriate to the setting because different environments (e.g., home vs. hospital) may require different approaches to pain management, ensuring that the interventions align with the patient's needs and the context.
B. Timely and logical delivery of pain relief interventions is critical for effective pain management. Delays in treatment can lead to unnecessary suffering and complicate the overall management of the patient's condition.
C. Asking about pain only once a shift is insufficient for effective pain management. Pain can fluctuate frequently, especially in a client with cancer, so regular assessment is essential to address pain promptly.
D. Believing that pain is what the client reports it to be is fundamental to effective pain management. Pain is subjective, and clients' experiences and expressions of pain should be taken seriously to guide appropriate interventions.
E. A team approach is often the most effective for pain management, as it allows for a comprehensive plan that integrates multiple perspectives and disciplines, including nursing, medical, and possibly palliative care professionals, ensuring a holistic approach to managing pain.

A. An irregular border. B. Asymmetrical shape. C. Been increasing in size. D. A diameter of less than 4 mm. E. Ecchymosis.

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

Explanation

A. An irregular border is a key characteristic of potentially cancerous skin lesions, particularly melanoma. Melanomas often have uneven, poorly defined edges.
B. Asymmetry is another sign of melanoma. If one half of a lesion does not match the other in shape or size, it should be evaluated by a healthcare professional.
C. Any lesion that has been increasing in size, particularly over a short period, is a concern and should be checked. Rapid growth can be a sign of malignancy.
D. A lesion with a diameter of less than 4 mm is generally less concerning, as most cancerous lesions are larger. However, the other factors (such as asymmetry and border irregularity) are more significant for diagnosis.
E. Ecchymosis (bruising) is not typically associated with cancerous skin lesions. Skin cancers like melanoma present as new or changing moles, not bruising.

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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

The nurse caring for a client diagnosed with pancreatic cancer understands that the key to effective pain management is: (SELECT ALL THAT APPLY)

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

Explanation

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

Explanation

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