A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?
Monro-Kellie hypothesis
Glasgow Coma Scale
Cranial nerve function
Mental status examination
The Correct Answer is B
A. Monro-Kellie hypothesis: The Monro-Kellie hypothesis explains the relationship between the volumes of brain tissue, blood, and cerebrospinal fluid in the cranium, but it is not a diagnostic tool for assessing LOC.
B. Glasgow Coma Scale: The Glasgow Coma Scale (GCS) is a standardized tool used to assess a client's level of consciousness, particularly in cases of head injury. It evaluates eye opening, verbal response, and motor response.
C. Cranial nerve function: Cranial nerve assessment is important in evaluating neurological function, but it is not a comprehensive tool for gauging LOC.
D. Mental status examination: A mental status examination assesses cognitive functions, but the Glasgow Coma Scale is more appropriate for evaluating LOC in the context of head trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Baked chicken: Baked chicken, if cooked thoroughly, is generally safe for a client with neutropenia (low WBC count) as it does not pose a high risk for infection.
B. Bagels: Bagels, if they are from a safe, uncontaminated source, are generally considered safe for neutropenic clients.
C. A factory-sealed box of chocolates: Factory-sealed chocolates are usually safe as they are unlikely to be contaminated.
D. Fresh fruit basket: Fresh fruits can carry bacteria, especially on the skin or peel, and pose a risk of infection for a client with neutropenia. Therefore, this is the item that should be prohibited.
Correct Answer is C
Explanation
A. Bradycardia: Alcohol withdrawal typically presents with tachycardia (increased heart rate), not bradycardia (decreased heart rate).
B. Hypotension: Alcohol withdrawal is more likely to cause elevated blood pressure rather than hypotension.
C. Elevated temperature: Elevated temperature is a common sign of alcohol withdrawal, which can be accompanied by other symptoms like tremors and agitation.
D. Slurred speech: Slurred speech is more associated with alcohol intoxication rather than withdrawal.
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