The practical nurse (PN) assists with a full neurological evaluation of a client with severe head trauma. Which client response to a painful stimulus indicates a significant neurologic problem?

Posturing with extension of the extremities.

Moaning with a grimace facial expression.

Withdrawal from the stimulus.

Increased respiratory rate.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Posturing with extension of the extremities: Decerebrate posturing, characterized by rigid extension of the arms and legs, indicates severe brain injury or dysfunction of the brainstem. This abnormal response reflects significant neurologic compromise and is associated with poor prognosis, requiring immediate attention and continued monitoring.

B. Moaning with a grimace facial expression: Vocalization and facial grimacing represent purposeful or reflexive responses to pain. While this indicates some level of neurological responsiveness, it does not reflect severe neurologic deterioration as posturing does.

C. Withdrawal from the stimulus: Flexion or withdrawal from painful stimuli is a normal protective reflex mediated by the spinal cord and indicates preserved motor function. This response is expected in clients with intact neurologic pathways.

D. Increased respiratory rate: Tachypnea may occur due to pain, anxiety, or other physiologic responses but does not specifically indicate severe neurologic injury. Respiratory changes alone are insufficient to identify critical neurologic compromise without other signs such as abnormal posturing.

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Correct Answer is A

Explanation

Rationale:

A. Uneven chest movements: Uneven or asymmetric chest expansion after a thoracentesis may indicate complications such as a pneumothorax or pleural effusion. This finding is clinically significant because it reflects impaired lung expansion and potential respiratory compromise, requiring immediate notification of the healthcare provider.

B. Gag reflex that has not returned: While assessing the gag reflex is important for airway protection, it is more relevant after procedures involving sedation, anesthesia, or airway instrumentation. Thoracentesis typically does not affect cranial nerve function or the gag reflex, making this finding less pertinent in this context.

C. Decrease in the baseline of the heart rate: A mild variation in heart rate may occur due to pain, anxiety, or activity, but a decrease alone without other symptoms such as hypotension or oxygen desaturation is not the most urgent indicator of post-thoracentesis complications.

D. Nasal congestion: Nasal congestion is unrelated to thoracentesis and does not reflect complications from the procedure. While it may require symptomatic management, it is not a priority finding for post-procedure monitoring.

A. Hematocrit of 44% (0.44 volume fraction). B. Serum potassium 2.5 mEq/L (2.5 mmol/L). C. Hemoglobin 13 grams/dL (130 g/L). D. Serum sodium 125 mEq/L (125 mmol/L). E. White blood cell count 15,000/mm3 (15 x 109/L).

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

Explanation

Rationale:

A. Hematocrit of 44% (0.44 volume fraction): This value falls within the normal reference range of 37%–47% for adult females. It indicates adequate red blood cell volume relative to plasma and does not require reporting to the healthcare provider.

B. Serum potassium 2.5 mEq/L (2.5 mmol/L): This value is below the normal range of 3.5–5.0 mEq/L, indicating hypokalemia. Low potassium levels can cause cardiac arrhythmias, muscle weakness, and respiratory compromise, necessitating immediate notification of the healthcare provider for intervention.

C. Hemoglobin 13 grams/dL (130 g/L): Hemoglobin within the range of 12–16 g/dL reflects adequate oxygen-carrying capacity and red blood cell mass. No abnormality is indicated, so it does not require reporting.

D. Serum sodium 125 mEq/L (125 mmol/L): This value is below the normal sodium range of 136–145 mEq/L, indicating hyponatremia. Hyponatremia can lead to neurological symptoms such as confusion, seizures, or lethargy, making it essential to report to the healthcare provider promptly.

E. White blood cell count 15,000/mm3 (15 x 10⁹/L): A WBC count above the reference range of 5,000–10,000/mm3 suggests leukocytosis, which may indicate infection, inflammation, or stress response. This abnormal finding should be communicated to the healthcare provider for further evaluation and management.

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The practical nurse (PN) assists with a full neurological evaluation of a client with severe head trauma. Which client response to a painful stimulus indicates a significant neurologic problem?

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Naxlex Comprehensive Predictor Exams

The day shift practical nurse (PN) is performing a focused assessment on a client who had a thoracentesis the evening before. The PN should alert the healthcare provider if the client exhibits which finding?

Correct Answer is A

Explanation

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

Explanation

The practical nurse (PN) listens for heart sounds by firmly pressing the diaphragm of the stethoscope against the client's chest. After hearing normal heart sounds, which action should the PN take to detect extra heart sounds?

When assessing a client's respiratory status, which technique should the practical nurse use to assess the anterior-posterior (AP) chest diameter?

The practical nurse (PN) is assessing the client's upper extremities muscle strength. The PN asks the client to extend the arms, but before asking the client to flex the arms, which action should the PN perform?

A college student arrives at the clinic for a physical examination and asks the practical nurse (PN) how he should perform testicular self-examination (TSE). Which information should the PN provide?

During the interviewing process, which action(s) should the practical nurse (PN) take when assessing a client's mood and affect? Select all that apply.

Which component(s) of cranial nerve function should the practical nurse (PN) evaluate during the focused assessment? Select all that apply.

A client comes to the clinic with concern about being unable to clearly see objects in the distance. The Snellen test results are 20/40 in the right eye and 20/30 in the left eye. Which action should the practical nurse (PN) implement?

Patient Data The practical nurse (PN) is doing a focused assessment on the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.