The nurse easily and quickly assesses changes in level of consciousness (eye opening, verbal responses motor response) using which neurological exams?

Glascow Coma Scale

NIH Stroke Scale

Romberg Test

Mini Mental Status Exam

Answer and Explanation

The Correct Answer is A

A) Glasgow Coma Scale:
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool used to assess a patient's level of consciousness based on three criteria: eye opening, verbal response, and motor response. Each of these categories is scored, and the total score helps to determine the depth of the patient's consciousness. The GCS is commonly used to monitor changes in a patient's neurological status, especially after trauma, stroke, or other conditions that may impair brain function.

B) NIH Stroke Scale:
The NIH Stroke Scale (NIHSS) is used to assess the severity of stroke symptoms and includes measures such as facial droop, arm and leg motor function, speech, and language abilities. It is used specifically to evaluate stroke symptoms and is not designed for the rapid assessment of general consciousness like the Glasgow Coma Scale.

C) Romberg Test:
The Romberg Test is a test of balance that is performed by having the patient stand with their feet together, eyes closed, and observing for any swaying or loss of balance. It is used to evaluate proprioception and cerebellar function, not to assess the level of consciousness.

D) Mini Mental Status Exam:
The Mini-Mental Status Exam (MMSE) is a brief cognitive screening tool that assesses aspects of cognitive function such as orientation, attention, memory, language, and visuospatial skills. While the MMSE can provide insight into cognitive function, it does not focus on the specific assessment of consciousness level (eye opening, verbal response, motor response) as the GCS does.

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Free Nursing Study Resources

Correct Answer is ["90"]

Explanation

Given:

Ordered dose of Alteplase: 0.9 mg/kg

Client weight: 220 pounds

Step 1: Convert the client's weight from pounds to kilograms:

1 pound (lb) = 0.453592 kilograms (kg)

Client weight in kg = 220 lbs x 0.453592 kg/lb = 99.76824 kg

Step 2: Calculate the total dose of Alteplase:

Total dose (mg) = Ordered dose (mg/kg) xClient weight (kg)

Total dose (mg) = 0.9 mg/kg x 99.76824 kg

Total dose (mg) = 89.801416 mg

Step 3: Round to the nearest whole number:

Total dose (mg) ≈ 90 mg

A. Urine output of 0.5-1 mL/kg/hr B. Serum sodium level 149 mEq/L. (normal 135-145) C. Blood pressure 82/54 D. Heart rate 124 beats per minute

Correct Answer is A

Explanation

A) Urine output of 0.5-1 mL/kg/hr:
This is a positive outcome during fluid resuscitation for burn patients. Adequate urine output is a key indicator of proper renal perfusion and fluid balance. A urine output of 0.5-1 mL/kg/hr is considered optimal for burn patients during the first 24-48 hours of resuscitation. It suggests that the kidneys are receiving sufficient blood flow and that the patient is responding appropriately to the fluids being administered.

B) Serum sodium level 149 mEq/L (normal 135-145):
A serum sodium level of 149 mEq/L is high and indicates hypernatremia, which is a common complication of excessive fluid resuscitation, particularly with the use of crystalloids. Hypernatremia can lead to cerebral edema, altered mental status, and other severe complications. Therefore, this finding would suggest improper fluid management and would not be considered a positive outcome.

C) Blood pressure 82/54:
A blood pressure of 82/54 is hypotensive, which is concerning in a burn patient. Hypotension indicates inadequate tissue perfusion, potentially leading to shock and organ failure. While low blood pressure may occur in the initial stages of resuscitation due to the rapid shifts in fluid, a sustained low blood pressure is not a positive outcome.

D) Heart rate 124 beats per minute:
A heart rate of 124 beats per minute is tachycardic and suggests that the patient is compensating for hypovolemia or inadequate circulatory volume, possibly due to insufficient fluid resuscitation. Although an elevated heart rate may occur as a compensatory mechanism in the initial stages of burn resuscitation, sustained tachycardia indicates ongoing volume depletion or inadequate perfusion and is not an ideal outcome.

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The nurse easily and quickly assesses changes in level of consciousness (eye opening, verbal responses motor response) using which neurological exams?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with an acute stroke must receive Alteplase 0.9 mg/kg. The client weighs 220 pounds. How should the client receive? (Round to the nearest whole number, do not use trailing zeros)

Correct Answer is ["90"]

Explanation

The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

Correct Answer is A

Explanation

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