The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?
Performing a mini mental status exam at admission and discharge
Performing serial Glasgow Coma Scale exams during hospitalization
Assessing pupils for reactivity, equality, symmetry and accommodation
Obtaining vital signs every four hours while hospitalized
The Correct Answer is B
A. Mini mental status exam at admission and discharge
Useful for cognitive function but not for acute changes.
B. Performing serial Glasgow Coma Scale exams
The GCS is the best tool for tracking changes in neurologic status over time.
C. Assessing pupils for reactivity, equality, symmetry, and accommodation
Important but not comprehensive.
D. Obtaining vital signs every four hours
Useful but does not specifically assess neurologic function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Atropine 1 mg IV push
A C3 spinal cord injury disrupts sympathetic control, causing bradycardia. Atropine is the first-line treatment for symptomatic bradycardia.
B. Epinephrine 1 mg IV
Epinephrine is used for cardiac arrest, not initial management of bradycardia.
C. Adenosine 6 mg IV push
Adenosine is used for supraventricular tachycardia, not bradycardia.
D. Milrinone 50 mcg/kg IV push
Milrinone is an inotrope used in heart failure, not bradycardia.
Correct Answer is B
Explanation
A. Provide the daughter and client with nutritional counseling.
While nutrition is important, assessing for abuse is the priority.
B. Interview the client alone and assess for abuse.
The client’s reluctance and daughter’s interruptions suggest potential elder abuse.
C. Take the history from the daughter due to the client’s confusion.
The client should be interviewed alone first.
D. Request a psychiatric evaluation.
Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.
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