A nurse is preparing to perform a neurological assessment on a client who has a head injury.
Which of the following tools should the nurse use to assess the client's level of consciousness?
Glasgow Coma Scale (GCS)
Mini-Mental State Examination (MMSE)
Confusion Assessment Method (CAM)
Morse Fall Scale (MFS)
The Correct Answer is A
The Glasgow Coma Scale (GCS) is a tool that measures the level of consciousness based on three parameters: eye opening, verbal response, and motor response. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness.
Incorrect options:
B) Mini-Mental State Examination (MMSE) - This is a tool that measures cognitive function, such as orientation, memory, attention, and language. It is not used to assess level of consciousness.
C) Confusion Assessment Method (CAM) - This is a tool that screens for delirium, which is an acute and fluctuating disturbance of cognition and attention. It is not used to assess level of consciousness.
D) Morse Fall Scale (MFS) - This is a tool that assesses the risk of falling in hospitalized clients based on six factors: history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. It is not used to assess level of consciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale: The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client's health status.
Incorrect options:
A) The client's vital signs are within normal limits. - This is a correct statement, but it is not the only information that should be documented.
B) The client's skin is warm, dry, and intact. - This is a correct statement, but it is not the only information that should be documented.
C) The client's bowel sounds are present in all four quadrants. - This is a correct statement, but it is not the only information that should be documented.
Correct Answer is D
Explanation
D) The client has an elevated troponin level in the blood.
Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.
A) The client has a history of hypertension and diabetes. - This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.
B) The client rates the pain as 8 on a scale of 0 to 10. - This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.
C) The client has crackles in the lower lobes of both lungs. - This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.
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