In the Neuro ICU (intensive care unit) while performing a neurological assessment of the patient the nurse noticed the patient: patient opens eyes, looks at you, responds slowly, and is somewhat confused. What level of consciousness (LOC) is this patient presenting?

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception?

An older adult is admitted for altered cognition. The spouse indicates the client has become more forgetful over time. The nurse assesses the client's cognition using the Mini-Cog. The client is able to draw a clock correctly but is unable to recall the three words given at the beginning of the assessment. What do the results suggest to the nurse?

A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply.

A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

A client presents to the health care clinic with a 3-day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5°F and pain with rotation of the head side to the side and decreased ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process?

A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?