Extract:

Question 1 of 5

How should the nurse evaluate the client's motor ability and function?

A. Inspect muscle symmetry in the upper and lower extremitiesB. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm of the bedC. Check plantar response and deep tendon-reflex testing bilaterallyD. Comparative cranial nerve assessments and ability to follow simple commands

Correct Answer: B

Rationale: Asking the client to perform tasks like squeezing a hand or lifting an arm directly assesses motor strength and coordination, key components of motor function.

Question 2 of 5

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

A. Laterally on the left side with a pillow under the head and the right arm and hand hyperextendedB. Supine with a pillow under the head, and elevate the right hand and arm on a pillowC. Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillowD. Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Correct Answer: C

Rationale: Semi-Fowler's position without a pillow and elevating the arm prevents contractures and promotes edema drainage.

Question 3 of 5

A client has sustained a crush injury to the abdomen as the result of an industrial accident. The initial assessment and interventions have been carried out. The vital signs are stable and the family is at the bedside. The client is complaining of bilateral flank pain. What is the priority nursing action for this client now?

A. Prepare for immediate abdominal surgeryB. Determine if there are any allergies to food or drugsC. Administer antibiotics as ordered after culture results are availableD. Obtain a urine specimen

Correct Answer: D

Rationale: Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. Testing urine for myoglobinuria or hematuria is the priority.

Question 4 of 5

The client presents with a complaint of 'always dropping things and falling down.' During the neurologic assessment, the nurse notices the client is unable to perform rapid alternating movements. Instead the client's response is very slow and misses often. What neurologic dysfunction would the nurse suspect?

A. inability to understand directionsB. Lesion of cranial nerve IXC. Dysfunction of the cerebellumD. Vestibular disease

Correct Answer: C

Rationale: The cerebellum controls coordination and fine motor movements. Inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.

Question 5 of 5

The nurse is caring for a client with SOB, wheezes, urticaria, itching and angioedema after receiving vancomycin IV. What is the priority nursing intervention after stopping the medication? Administer:

A. diphenhydramine 50mg PO.B. famotidine 40mg PO.C. epinephrine 1mg IM.D. a fluid bolus of normal saline.

Correct Answer: C

Rationale: Epinephrine is the first-line treatment for anaphylaxis, reversing airway swelling, hypotension, and bronchoconstriction.