Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?

Correct Answer: D

Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.

Correct Answer: D

Rationale: Consistent limit setting is an effective nursing intervention for managing impulsive and aggressive behaviors in individuals with conduct disorder. By establishing clear and consistent boundaries, rules, and consequences, individuals with conduct disorder can learn self-control and appropriate behavior. Consistent limit setting provides structure and predictability, helping to reduce impulsive and aggressive reactions in these individuals. It also teaches them accountability for their actions and reinforces appropriate behavior. Additionally, setting limits helps to establish a sense of safety and security for both the individual and those around them. Therefore, consistent limit setting is a crucial intervention to help manage impulsive and aggressive behaviors associated with conduct disorder.

Correct Answer: C

Rationale: An assumption is a belief or statement that is accepted as true without proof. In this case, the statement suggests a belief that the length of service does not affect the degree of patient safety practices among staff nurses, without providing evidence or data to support this claim. It is an assumption about the relationship between two variables without a proper basis or evidence to back it up, making it an example of an assumption.

Correct Answer: C

Rationale: The most appropriate response by the nurse is, "If I were you, I will get a second opinion." This response acknowledges the seriousness of the situation and the life-changing decision the patient has been told to make. Suggesting the patient seek a second opinion is essential as it encourages the patient to explore all options and ensures they have considered all possibilities before proceeding with a major surgery like an above-the-knee amputation. It shows the nurse's support for the patient while also advocating for the patient's right to make an informed decision about their healthcare.

Correct Answer: A

Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.