To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:
push the soles of the feet against the nurse's hands.
wiggle the toes of both feet at the same time.
pull both feet up at the same time to stretch the Achilles tendons.
stand up independently
The Correct Answer is A
A. Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B. Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C. Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D. Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pulse deficit refers to the difference between the apical and radial pulse, not a silence between sounds during blood pressure measurement.
B. Diastolic refers to the phase of the blood pressure cycle when the heart is at rest, not to a silent period.
C. An auscultatory gap is a period of silence between the systolic and diastolic sounds heard when taking blood pressure. It can be indicative of arterial stiffness or other vascular issues.
D. Widened pulse pressure refers to the difference between systolic and diastolic pressures, not a silence during auscultation.
Correct Answer is A
Explanation
A. Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B. While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C. At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D. While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.
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