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 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.

A. Tell the adolescent everything will be fine and there's nothing to worry about. B. Complete an assessment and notify the emergency department physician immediately. C. Perform a focused assessment and document. D. Document pain assessment as normal.

Correct Answer is B

Explanation

A. Reassurance is important, but it should be given after a thorough assessment and appropriate actions have been taken.
B. Completing an assessment and promptly informing the physician allows for timely intervention in case of testicular torsion or other serious conditions causing severe testicular pain.
C. Performing a focused assessment is crucial but shouldn't delay immediate notification of the physician in such a critical situation.
D. Documenting pain assessment is important but not the priority when a client presents with severe, acute pain in a sensitive area like the testicles.

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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?

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Naxlex Comprehensive Predictor Exams

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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?