A nurse is assessing a client on the musculoskeletal floor and identifies symptoms of weak pulses, dusky color in the ankles, and 3+ local edema. Which of the following does the nurse suspect to be an issue with this client?

Correct Answer: A

Rationale: In this scenario, the nurse suspects that the client is experiencing problems with circulation, which is the correct answer (Option A). Weak pulses, dusky color in the ankles, and significant local edema are indicative of impaired blood flow to the lower extremities. This could be due to conditions such as peripheral vascular disease or deep vein thrombosis, which can lead to serious complications if not addressed promptly. Option B, problems with sensation, is incorrect in this case because the symptoms described are more closely related to circulatory issues rather than sensory deficits. Problems with sensation would typically involve issues such as numbness, tingling, or loss of feeling in the affected area. Option C, problems with mobility, is also incorrect as the symptoms presented do not directly point to issues with the client's ability to move. While impaired circulation can impact mobility in the long term if left untreated, it is not the primary concern based on the symptoms provided. Option D, problems with pain, is not the most likely issue as the symptoms described are more indicative of compromised blood flow rather than pain perception. While the client may eventually experience pain if circulation is severely compromised, the initial symptoms point more towards circulatory issues. From an educational perspective, understanding the signs and symptoms of circulatory problems in the lower extremities is crucial for nurses working in various clinical settings. Recognizing these indicators early can help prevent complications such as tissue damage, ulceration, and even amputation. Nurses should be able to differentiate between circulatory issues, sensory deficits, mobility problems, and pain to provide timely and appropriate care to their patients.

Correct Answer: A

Rationale: The correct answer is A) Swelling due to the initial trauma may make the injury seem more severe than it actually is. A more accurate assessment will be made once the swelling goes down. This response is the best because in cases of acute trauma such as an automobile accident, immediate swelling and inflammation can mask the true extent of the injury. It is important to wait until the swelling decreases to assess the patient's condition accurately. Jumping to conclusions or making assumptions based on initial presentation can lead to incorrect diagnoses and inappropriate interventions. Option B is incorrect because it is a simplistic explanation that does not consider the complexity of the situation. It does not provide a comprehensive or accurate assessment of the patient's condition. Option C is incorrect because while rehabilitation centers may be beneficial for some patients, the immediate concern in this situation is assessing the extent of the injury and providing appropriate acute care. Option D is incorrect because it is not relevant to the immediate medical assessment and care needed for the patient's current condition. It is important to focus on the patient's current symptoms and needs rather than placing blame or discussing preventative measures at this moment. In an educational context, this question highlights the importance of thorough assessment and critical thinking in emergency situations. It emphasizes the need to consider factors such as swelling and initial presentation when evaluating a patient's condition. It also underscores the significance of avoiding premature conclusions and ensuring a comprehensive evaluation before determining a course of action.

Correct Answer: C

Rationale: In the context of preparing a patient with carpal tunnel syndrome for surgery, delegating assisting the patient with daily self-care measures such as bathing and eating to the nursing assistant is the most appropriate intervention. This task falls within the scope of the nursing assistant's role and is essential for ensuring the patient's comfort and hygiene during the pre-operative period. Option A, initiating the placement of a splint for immobilization during the day, involves a more specialized skill that should be performed by a licensed healthcare provider, such as a nurse or physician. While assessing the patient's wrist and hand for discoloration and brittle nails (Option B) is important in the overall assessment of carpal tunnel syndrome, it is not directly related to preparing the patient for surgery. Testing the patient for painful tingling in the four digits of the hand (Option D) is a clinical assessment task that requires specialized knowledge and should be performed by a nurse or healthcare provider. Delegating appropriate tasks to the nursing assistant not only optimizes the efficiency of care but also ensures that each team member is working within their scope of practice, promoting safe and effective patient care.

Correct Answer: D

Rationale: The correct answer is D) Central nervous system. When a client is undergoing neurological testing for a brain tumor, it primarily affects the central nervous system (CNS) because the brain tumor is located within the brain or spinal cord, which are components of the CNS. Testing for a brain tumor involves assessing the structures and functions of the brain and spinal cord, which are part of the CNS. Option A) Peripheral nervous system is incorrect because the peripheral nervous system consists of nerves outside the brain and spinal cord, and a brain tumor does not directly affect these peripheral nerves. Option B) Autonomic nervous system is incorrect because while the autonomic nervous system is a division of the peripheral nervous system that regulates involuntary bodily functions like heart rate and digestion, it is not the primary division affected by a brain tumor. Option C) Sympathetic nervous system is incorrect because it is a part of the autonomic nervous system, which as mentioned earlier, is not the main division affected in a client with a brain tumor. Educationally, understanding the divisions of the nervous system is crucial for healthcare professionals as it helps in accurate assessment, diagnosis, and treatment of neurological conditions. Knowing which division is primarily affected in specific conditions like brain tumors guides healthcare providers in providing appropriate care and interventions.

Correct Answer: D

Rationale: In this scenario, the nurse should suspect Myasthenia gravis (MG) based on the client's symptoms of ptosis, difficulty chewing and swallowing, diplopia, voice weakness, masklike facial expression, and extremity weakness. MG is an autoimmune neuromuscular disorder characterized by muscle weakness and fatigue. These specific symptoms align with the hallmark features of MG due to the involvement of the neuromuscular junction. Option A, Parkinson's disease, is characterized by tremors, rigidity, bradykinesia, and postural instability, not the symptoms described in the question. Option B, Extrapyramidal disorder, encompasses a group of movement disorders affecting the extrapyramidal system but does not typically present with the specific combination of symptoms mentioned. Option C, Multiple sclerosis, is a central nervous system disorder that involves demyelination of nerve fibers, leading to a variety of symptoms, but it does not typically cause the specific neuromuscular junction-related symptoms seen in this case. Educationally, understanding the distinct clinical manifestations of different neurological conditions is crucial for accurate diagnosis and effective patient care. Recognizing the specific symptoms associated with MG can aid nurses in providing timely interventions, such as administering acetylcholinesterase inhibitors or immunosuppressants, and monitoring for myasthenic crises. This case underscores the importance of clinical assessment, knowledge of pathophysiology, and critical thinking in the care of patients with neurological conditions.