The nurse is caring for the following clients. Which client would the nurse assess first after receiving shift report?
The client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
The client diagnosed with a cerebrovascular accident who has expressive aphasia.
The client diagnosed with a concussion who is complaining about being woken up every two hours.
The client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6.
The Correct Answer is D
Choice A reason: Left-sided weakness suggests a possible stroke, requiring urgent evaluation, but a scheduled MRI indicates initial assessment has occurred. The client’s condition appears stable enough for diagnostic planning, suggesting no immediate life-threatening deterioration. This is less urgent than a client with a critically low Glasgow Coma Scale score indicating severe neurological compromise.
Choice B reason: Expressive aphasia in a client with a confirmed cerebrovascular accident indicates a stable neurological deficit post-stroke. While significant, this condition is not immediately life-threatening, and ongoing monitoring is likely in place. The priority is lower than a client with acute, severe neurological impairment indicated by a critically low Glasgow Coma Scale score.
Choice C reason: A concussion patient complaining about frequent wake-ups is likely stable, as routine neurological checks are standard protocol. The complaint reflects discomfort rather than acute deterioration. This is less urgent than a client with a Glasgow Coma Scale score of 6, which indicates severe neurological compromise requiring immediate assessment.
Choice D reason: A Glasgow Coma Scale score of 6 indicates severe neurological impairment, likely from traumatic brain injury after a motorcycle accident. This score reflects critical deficits in eye-opening, verbal, and motor responses, signaling potential life-threatening conditions like brain swelling or hemorrhage. Immediate assessment is essential to prevent further deterioration or death, making this the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Nuchal rigidity is neck stiffness resisting passive flexion, common in meningitis, but it does not involve leg flexion. The described involuntary leg movement is specific to Brudzinski’s sign, making this choice incorrect for the observed symptom.
Choice B reason: Kernig’s sign involves pain or resistance when extending the knee with the hip flexed, not involuntary leg flexion during neck movement. The client’s presentation aligns with Brudzinski’s, not Kernig’s, making this choice incorrect.
Choice C reason: Bradykinesia, slow movement, is associated with Parkinson’s disease, not meningitis. It does not involve involuntary leg flexion with neck movement, making this choice irrelevant to the client’s meningeal symptom presentation.
Choice D reason: Brudzinski’s sign is positive when neck flexion causes involuntary hip and knee flexion in meningitis, due to meningeal irritation. The client’s leg flexion during neck movement matches this, making it the correct condition displayed.
Correct Answer is A
Explanation
Choice A reason: Major depressive disorder carries the highest suicide risk due to severe, pervasive symptoms like hopelessness and anhedonia, driven by profound serotonin and norepinephrine dysregulation in the brain. These neurochemical imbalances impair emotional regulation and impulse control, significantly increasing the likelihood of suicidal ideation and behavior compared to other depressive disorders.
Choice B reason: Seasonal affective disorder involves depressive episodes tied to seasonal changes, likely due to reduced serotonin from decreased sunlight exposure. While serious, its cyclical nature and milder severity compared to major depressive disorder result in a lower suicide risk, as symptoms often remit with environmental or therapeutic interventions.
Choice C reason: Premenstrual dysphoric disorder causes mood disturbances linked to hormonal fluctuations, affecting serotonin and GABA systems premenstrually. Its episodic, time-limited nature reduces suicide risk compared to major depressive disorder, as symptoms resolve post-menstrually, and it rarely reaches the severity or persistence associated with high suicidality.
Choice D reason: Persistent depressive disorder involves chronic, milder depressive symptoms, with less intense neurochemical disruptions than major depressive disorder. While it impacts quality of life, its lower severity and chronicity reduce acute suicide risk compared to the severe, episodic hopelessness and despair characteristic of major depressive disorder.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.