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 D

Explanation

Choice A reason: Presence of a synthetic silicone mesh stent in a coronary artery is not a contraindication for MRI. Silicone is a non-magnetic material that does not interfere with the magnetic field or cause any harm to the patient or the device.

Choice B reason: Allergy to shellfish and iodine is not a contraindication for MRI. Shellfish and iodine are not related to the contrast agent used for MRI, which is usually gadolinium. However, the patient should inform the provider if they have any history of allergic reactions to contrast agents or any other medications.

Choice C reason: Contact lenses are not a contraindication for MRI. Contact lenses are made of plastic or silicone, which are non-magnetic materials that do not interfere with the magnetic field or cause any harm to the patient or the device. However, the patient should remove them before the procedure to avoid any discomfort or irritation.

Choice D reason: Presence of an internal insulin pump in the abdomen is a contraindication for MRI. Insulin pumps are electronic devices that contain metal parts, batteries, and wires, which can be affected by the magnetic field and cause malfunction, damage, or injury to the patient or the device. Therefore, the patient should inform the provider and the MRI technician about the insulin pump and follow their instructions on how to manage it before, during, and after the procedure.

A. macrocytic, normochromic B. microcytic, hypochromic C. normocytic, normochromic D. microcytic, normochromic

Correct Answer is A

Explanation

Choice A reason: This is correct. Folic acid deficiency causes macrocytic, normochromic anemia, which means that the red blood cells are larger than normal, but have normal color and hemoglobin content. Folic acid is a vitamin that is needed for the synthesis of DNA and the maturation of red blood cells.

Choice B reason: This is incorrect. Microcytic, hypochromic anemia means that the red blood cells are smaller than normal and have less color and hemoglobin content. This type of anemia is caused by iron deficiency, not folic acid deficiency.

Choice C reason: This is incorrect. Normocytic, normochromic anemia means that the red blood cells are normal in size, color, and hemoglobin content, but there are fewer of them. This type of anemia is caused by blood loss, hemolysis, or bone marrow failure, not folic acid deficiency.

Choice D reason: This is incorrect. Microcytic, normochromic anemia means that the red blood cells are smaller than normal, but have normal color and hemoglobin content. This type of anemia is rare and is caused by disorders of red blood cell production, such as thalassemia or sideroblastic anemia, not folic acid deficiency.

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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?

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