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
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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Related Questions
Correct Answer is C
Explanation
A. Anorexia refers to a loss of appetite or lack of interest in food, not difficulty swallowing.
B. Aphasia is a language disorder that affects a person's ability to communicate, not related to swallowing difficulties.
C. Dysphagia is the medical term for difficulty swallowing, which can involve medications and food, potentially due to various causes like neurological conditions or structural issues.
D. Dysphasia refers to difficulty with speech or language, not directly related to swallowing difficulties.
Correct Answer is B
Explanation
A. The Glasgow Coma Scale assesses a patient's level of consciousness, not specifically limb weakness.
B. A complete neurological examination would involve assessing cranial nerves, motor and sensory functions, reflexes, coordination, and gait, which are essential when a client presents with unilateral weakness in the arm and leg.
C. A muscular examination might focus more on muscle strength and tone but might not cover the breadth of neurological assessment needed in this scenario.
D. Neurologic recheck examination suggests a reassessment after an initial neurological exam but doesn’t specify the need for a comprehensive evaluation.
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