A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

Fever.

Visual disturbance.

Gait alteration.

Hypoxia.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Fever is typically regulated by the hypothalamus, a part of the brain that controls body temperature. Dysfunction of the lower brain stem does not typically cause fever.

Choice B rationale

Visual disturbances are often related to issues with the visual cortex or optic pathways, which are not part of the lower brain stem.

Choice C rationale

Gait alteration is typically associated with dysfunction in the cerebellum or motor pathways, rather than the lower brain stem.

Choice D rationale

Hypoxia, or decreased oxygen levels, can be a critical concern with lower brain stem dysfunction as the lower brain stem controls vital autonomic functions such as respiration and heart rate.

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Correct Answer is A

Explanation

Choice A rationale

Assessing the client's verbal response is the first step in evaluating their level of consciousness (LOC). It provides immediate information about their ability to communicate and follow commands.

Choice B rationale

Assessing the client's response to pain is a later step in the LOC assessment if the client does not respond to verbal stimuli. It helps determine the level of consciousness if the client is not verbally responsive.

Choice C rationale

Assessing the client's judgment is part of a cognitive assessment but is not the first action when assessing LOC. It evaluates higher brain functions, not the initial level of responsiveness.

Choice D rationale

Assessing the client's ability to follow complex commands is part of a cognitive assessment and provides information about higher brain function but is not the first step in LOC assessment.

A. Bradycardia. B. Bradypnea. C. Hypertension. D. Tachycardia.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Bradycardia (slow heart rate) is one of the key components of Cushing's triad, which indicates increased intracranial pressure and impending herniation.

Choice B rationale

Bradypnea (slow respiratory rate) is another manifestation of Cushing's triad and reflects brainstem compression.

Choice C rationale

Hypertension (high blood pressure) is the third component of Cushing's triad, resulting from the body's attempt to maintain cerebral perfusion.

Choice D rationale

Tachycardia (rapid heart rate) is not a sign of Cushing's triad and is not associated with increased intracranial pressure.

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A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Correct Answer is A

Explanation

Which signs are manifestations of the Cushing triad? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

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