Page 2055 - Saunders Comprehensive Review For NCLEX-RN

unit. The client has complaints of inability to move both legs and reports a
tingling sensation above the waistline. Knowing the complications of the
disorder, the nurse should bring which most essential items into the client’s
room?
1. Nebulizer and pulse oximeter
2. Blood pressure cuff and flashlight
3. Nasal cannula and incentive spirometer
4. Electrocardiographic monitoring electrodes and intubation tray

Answers

704. Answer: 2

Rationale: Nailbed pressure tests a basic motor and sensory peripheral response.
Cerebral responses to pain are tested using a sternal rub, placing upward pressure
on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
Test-Taking Strategy: Focus on the subject, testing peripheral response to pain.
The nailbeds are the most distal of all options and are therefore the most peripheral.
Each of the other options may elicit a generalized response, but not a localized one.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Head injury/trauma
Priority Concepts: Intracranial Regulation; Pain
Reference: Ignatavicius, Workman, Rebar (2018), pp. 441-443.

705. Answer: 2

Rationale: A change in vital signs may be a late sign of increased intracranial
pressure. Trends include increasing temperature and blood pressure and decreasing
pulse and respirations. Respiratory irregularities also may occur.
Test-Taking Strategy: Focus on the subject, signs of increased intracranial
pressure. If you remember that the temperature rises, you are able to eliminate
options 3 and 4. If you know that the client becomes bradycardic, or know that the
blood pressure rises, you are able to select the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Head injury/trauma
Priority Concepts: Clinical Judgment; Intracranial Regulation
Reference: Lewis et al. (2017), pp. 1318-1319.

706. Answer: 4

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