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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Stop transfusion, run normal saline is correct because the client is likely experiencing an acute hemolytic transfusion reaction (AHTR), which is life-threatening. The priority is to stop the transfusion immediately and maintain IV access with normal saline to prevent further hemolysis.

B. Administer morphine IV is incorrect because pain management is important, but stopping the transfusion is the immediate priority.

C. Administer epinephrine IM is incorrect because epinephrine is used for anaphylaxis, not hemolytic reactions.

D. Continue to monitor the infusion is incorrect because the transfusion must be stopped immediately to prevent worsening hemolysis.

A. Notify the physician and anticipate the need for endotracheal intubation B. Place the client in semi-fowler's position and administer albuterol breathing treatment C. Encourage the client to cough, take deep breaths, and then auscultate again D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry

Correct Answer is A

Explanation

A. Notify the physician and anticipate the need for endotracheal intubation
The client is showing progressive airway obstruction due to inhalation injury. The absence of wheezes indicates impending respiratory failure, requiring immediate airway management.

B. Place the client in semi-Fowler's position and administer an albuterol breathing treatment
Albuterol may help bronchospasm, but this client's issue is upper airway swelling, not bronchospasm. Intubation is the priority.

C. Encourage the client to cough, take deep breaths, and then auscultate again
The loss of wheezes suggests airway swelling has worsened, not that secretions are the issue. Immediate intervention is needed.

D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry
Guaifenesin and incentive spirometry help with secretion clearance, but they are not the priority in this emergent airway situation.

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The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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