An older adult is admitted to the hospital following a closed head injury from a fall that resulted in a 5-minute period of unconsciousness. Which priority nursing assessment indicates neurological deterioration in the patient?

Polyphasia and nystagmus

Increased respiratory rate and depth.

Decreased level of consciousness and difficulty arousing upon stimulation.

Decreased pulse pressure and pupils slowly reactive and round to light.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect. Polyphasia and nystagmus are not signs of neurological deterioration, but rather of speech and eye disorders. Polyphasia is the excessive use of words or speech, and nystagmus is the involuntary movement of the eyes.

Choice B reason: This is incorrect. Increased respiratory rate and depth are not signs of neurological deterioration, but rather of respiratory distress or hyperventilation. They may indicate a problem with the lungs or the blood gases, not the brain.

Choice C reason: This is correct. Decreased level of consciousness and difficulty arousing upon stimulation are signs of neurological deterioration, as they indicate a decrease in the brain's ability to function and respond to stimuli. They may be caused by increased intracranial pressure, bleeding, swelling, or infection in the brain.

Choice D reason: This is incorrect. Decreased pulse pressure and pupils slowly reactive and round to light are not signs of neurological deterioration, but rather of cardiovascular or autonomic dysfunction. They may indicate a problem with the heart or the blood pressure, not the brain.

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Correct Answer is A

Explanation

Choice A reason:Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.

Choice B reason:Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.

Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.

Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.

A. attempt to take over the function of the abnormal white blood cells. B. will help to protect them against infection. C. are larger in size than normal white blood cells and clog the bone marrow. D. are not as effective as normal white cells to protect against infection.

Correct Answer is D

Explanation

Choice A reason: This is not a correct explanation for the large number of leukemic white cells. Leukemic white cells are abnormal white blood cells that do not function properly. They do not attempt to take over the function of the abnormal white blood cells, but rather crowd out the normal ones.

Choice B reason: This is also not a correct explanation for the large number of leukemic white cells. Leukemic white cells do not help to protect against infection, but rather increase the risk of infection. They impair the immune system's ability to fight off bacteria, viruses, and other pathogens.

Choice C reason: This is a partially correct explanation for the large number of leukemic white cells. Leukemic white cells are larger in size than normal white blood cells, and they can clog the bone marrow. This can interfere with the production of other blood cells, such as red blood cells and platelets. However, this is not the only reason for the large number of leukemic white cells.

Choice D reason: This is the best explanation for the large number of leukemic white cells. Leukemic white cells are not as effective as normal white cells to protect against infection, because they are immature and dysfunctional. They do not respond to signals from the immune system, and they do not recognize or destroy foreign invaders. They also prevent the normal white cells from doing their job.

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An older adult is admitted to the hospital following a closed head injury from a fall that resulted in a 5-minute period of unconsciousness. Which priority nursing assessment indicates neurological deterioration in the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes a Romberg's test on a patient with neurologic changes. The nurse will notify the provider if they observe which response?

Correct Answer is A

Explanation

A patient with acute myelogenous leukemia (AML) asks the nurse why their bones are making more white blood cells when they already have so many. The nurse clarifies that the large number of leukemic white cells they have:

Correct Answer is D

Explanation

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