The same patient reports that he was able to sleep through the night.
However, he notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers.
He also reports mild nausea and has no desire to eat breakfast.
There is a 3 cm by 5 cm area of blood noted on the bandage.
His left arm is warm to touch.
His left shoulder and collarbone are symmetric.
As a nurse, which findings would indicate that the patient is progressing as expected?
The patient was able to sleep through the night.
The patient’s left arm is warm to touch.
The patient’s left shoulder and collarbone are symmetric.
The patient has no desire to eat breakfast.
Correct Answer : A,B,C
Choice A rationale
The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.
Choice B rationale
The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.
Choice C rationale
The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.
Choice D rationale
The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","F"]
Explanation
Choice A rationale
Assisting the client to the bathroom is appropriate as clonazepam can cause dizziness and unsteadiness, increasing the risk of falls.
Choice B rationale
Having an opioid agonist at the bedside is not necessary for a client starting clonazepam. Clonazepam is a benzodiazepine, not an opioid.
Choice C rationale
Providing oral care at least twice a day is generally good practice for all patients, but it’s not specifically related to clonazepam use.
Choice D rationale
Assessing mental status regularly is crucial as clonazepam can cause changes in mood and behavior.
Choice E rationale
Monitoring calcium levels is not typically required for a client starting clonazepam.
Choice F rationale
Screening for orthostatic hypotension is important as clonazepam can lower blood pressure, leading to dizziness and fainting when the client stands up.
Correct Answer is ["C"]
Explanation
Choice A rationale
The patient is resting and cooperative, which indicates a calm and alert state, not agitation. Orientation x means the patient is aware of person, place, time, and situation, which is a normal finding. Dizziness is not mentioned in the patient’s condition. Pupils being equal and reactive to light is a normal finding and does not indicate a neurological issue.
Choice B rationale
Bradycardia refers to a slower than normal heart rate, which is not mentioned in the patient’s condition. Weak bilateral radial pulses could indicate poor blood circulation, but this is not mentioned in the patient’s condition. Capillary refill of 2 seconds is a normal finding. The absence of lower leg edema is a normal finding and does not indicate a cardiovascular issue.
Choice C rationale
Clear breath sounds are a normal finding and indicate that the patient’s lungs are free of obstructions or fluid.
Choice D rationale
The last reported bowel movement being 4 days ago could indicate constipation, but this is not mentioned in the patient’s condition.
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