The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?

ability to swallow pureed foods

client reports mild headache

Weakness

Glasgow coma scale of 5

Answer and Explanation

The Correct Answer is D

A.   Ability to swallow pureed foods suggests some functional capacity and is not an immediate concern requiring immediate reporting.
B.   A mild headache reported by the client might not indicate a critical issue requiring immediate reporting.
C.   Weakness can be a concerning symptom, but the severity or extent of weakness needs further clarification before urgent reporting.
D.   A Glasgow Coma Scale (GCS) score of 5 is indicative of severe impairment of consciousness, requiring immediate attention and further evaluation by the healthcare provider.

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Correct Answer is C

Explanation

A. Iron supplements typically lead to darker stools but may not necessarily present as a non-tarry black stool.
B. Dry heaves or vomiting could potentially indicate upper gastrointestinal bleeding but not specifically correlate with non-tarry black stool.
C. Consuming red meat can cause black stools due to its breakdown products, which is a normal finding.
D. Loss of appetite doesn't directly relate to stool color or consistency.

A. Heart failure B. Excess fluid retention C. Excess fluid consumption D. Pulmonary embolism

Correct Answer is A

Explanation

A. Heart failure can lead to fluid accumulation in the legs due to the heart's inability to effectively pump blood, causing increased pressure in the veins.
B. Excess fluid retention or consumption might cause edema, but heart failure specifically impacts the heart's pumping function.
C. Excess fluid consumption might contribute to temporary edema, but severe bilateral lower extremity edema is more likely due to a systemic issue like heart failure.
D. While a pulmonary embolism can lead to edema in the legs, it typically presents with sudden onset and might not present with bilateral edema from feet to knees.

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA). Which of the following findings should the nurse report to the practitioner immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?