The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Level of consciousness.

Focal neurological exam.

Body posturing.

Vital signs.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

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Correct Answer is D

Explanation

Choice A reason:

While assisting the client into a wheelchair and coaching deep coughing can be beneficial, it does not specifically describe the technique for performing assistive coughing, which is crucial for a quadriplegic patient who cannot generate effective coughs on their own.

Choice B reason:

Placing the client in a high-Fowler position and encouraging deep breaths can be helpful in enhancing lung expansion and breathing, but it does not address the specific method of assistive coughing, which requires manual assistance to be effective.

Choice C reason:

Placing hands on the lateral chest and pushing inward on exhalation is not the correct technique for assistive coughing. This method may not generate sufficient force to help with airway clearance in a quadriplegic patient.

Choice D reason:

Placing hands below the client's diaphragm and pushing upward with exhalation is the correct technique for assistive coughing, also known as quad coughing. This method helps to increase the force of the cough, allowing for better clearance of secretions from the airway, which is essential for patients with quadriplegia.

A. Serum blood glucose of 128 mg/dL B. Blood pressure of 83/51 mmHg C. Hemoglobin level of 13 g/dL D. Core body temperature of 97.8 degrees F

Correct Answer is B

Explanation

Choice A reason:

A serum blood glucose level of 128 mg/dL is slightly elevated but not immediately concerning in the context of organ donation. Blood glucose levels can be managed with insulin if necessary, and this value does not indicate an acute issue requiring immediate intervention.

Choice B reason:

A blood pressure of 83/51 mmHg is critically low and requires immediate action. Low blood pressure can compromise organ perfusion and oxygen delivery, potentially leading to organ damage. In the context of organ donation, maintaining adequate perfusion pressure is essential to ensure the viability of the organs for transplantation.

Choice C reason:

A hemoglobin level of 13 g/dL is within the normal range and does not require immediate intervention. Hemoglobin levels are important for oxygen-carrying capacity but are not the priority concern six hours before organ harvesting if the value is within normal limits.

Choice D reason:

A core body temperature of 97.8 degrees F is slightly below normal but not immediately alarming. Mild hypothermia can be addressed with warming measures, and this temperature does not indicate a critical issue that requires urgent action.

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The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

Correct Answer is D

Explanation

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse?

Correct Answer is B

Explanation

Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

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The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?