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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A peritoneal friction rub is a grating sound caused by inflamed surfaces of the peritoneum rubbing together.
B. Borborygmi refers to loud, gurgling bowel sounds often heard with increased intestinal motility.
C. Hypoactive bowel sounds are abnormally decreased or absent bowel sounds.
D. Borborygmi describes the normal sounds made by the movement of gas and fluid in the intestines.
Correct Answer is A
Explanation
A. Osteoporosis involves a reduction in bone density, making bones weaker and more susceptible to fractures.
B. Osteoporosis doesn't refer to new bone growth; instead, it involves the weakening of existing bone structure.
C. While calcium intake is crucial for bone health, osteoporosis is a multifactorial condition influenced by various factors beyond just calcium intake.
D. Osteoporosis can occur in menopausal women due to hormonal changes, but it's not solely attributed to the lack of hormone replacement therapy. Hormones play a role in bone health, but osteoporosis is fundamentally about bone density loss.
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