The nurse is preparing to collect data for a patient's neurological status. What equipment should the nurse gather?

Blood pressure cuff

Pen light

Thermometer

Stethoscope

Answer and Explanation

The Correct Answer is B

A. A blood pressure cuff is not directly needed to assess neurological status. While blood pressure is important to monitor in neurological assessments, it is not the primary tool used for assessing neurological function.

B. A pen light is essential for assessing pupil reaction, which is a key part of a neurological exam. The nurse can use the pen light to check for pupil dilation, constriction, and reaction to light, which are important indicators of brain function.

C. A thermometer is useful for measuring body temperature but is not a primary tool for assessing neurological status. Although fever can be a sign of infection affecting the brain, it is not part of the basic neurological exam.

D. A stethoscope is useful for listening to heart and lung sounds, but it is not typically used for assessing neurological function. The pen light is the more appropriate tool for this purpose.

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Correct Answer is D

Explanation

A. The client should not sit upright in a chair for prolonged periods (such as 4 hours at a time) immediately following spinal fusion, as this could place excessive strain on the surgical site. The client should be assisted to sit upright for short periods and be repositioned regularly.

B. Clear drainage on the spinal dressing could indicate cerebrospinal fluid leakage, which is a concern following spinal surgery. The nurse should expect minimal to no drainage, and if clear fluid is observed, it should be reported immediately.

C. Elevating the client's legs when lying on his side may not be necessary unless specifically ordered by the healthcare provider. In general, the client should maintain proper body alignment and avoid any positions that strain the surgical site.

D. Log rolling is a critical intervention for spinal fusion patients to prevent twisting of the spine. The nurse should assist the client in log rolling every 2 hours to maintain spinal alignment and prevent injury to the surgical site.

A. "All family members are now at risk for the disease." B. "Only your children need to be tested for a genetic connection." C. "If you are not diagnosed by age 20, you are considered safe." D. "You definitely need to have genetic testing for the disease."

Correct Answer is A

Explanation

A. Huntington disease is an autosomal dominant genetic disorder, meaning that if one parent has the gene, each child has a 50% chance of inheriting it. Therefore, all family members are at risk for the disease.

B. While genetic testing may be relevant for the patient’s children, it is not limited only to them. The patient and other family members are also at risk and may choose to be tested.

C. Huntington disease typically manifests between ages 30 and 50, and there is no age cutoff for determining risk. Early diagnosis may occur, but not being diagnosed by age 20 does not rule out the disease.

D. While genetic testing can confirm the presence of the gene, it is not the only way to determine risk. Family history and clinical symptoms are also key factors in understanding the risk for Huntington disease.

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The nurse is preparing to collect data for a patient's neurological status. What equipment should the nurse gather?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A patient is distressed to learn that a sibling is diagnosed with both neurologic and cognitive manifestations of Huntington disease. When the patient asks the nurse how to determine the incidence of the disease, which answer is most appropriate?

Correct Answer is A

Explanation

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