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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","E"]

Explanation

A. A
Patients with A- blood type have A antigens on their red blood cells and do not have the Rh factor (negative). They can receive A- blood because it has the same antigens and Rh factor, making it a perfect match.

B. O+
Rh-negative clients cannot receive Rh-positive blood, as it may trigger an immune reaction.

C. AB-
Type AB blood contains A and B antigens, which A- individuals do not naturally have, increasing the risk of a transfusion reaction.

D. A+
A Rh-negative (A-) client cannot receive Rh-positive (A+) blood due to the risk of Rh sensitization.

E. O-
O- blood is the universal donor for red blood cells, meaning it contains no A, B, or Rh antigens, making it safe for an A- recipient.

A. initial stage of septic shock. B. refractory stage of obstructive shock. C. progressive stage of hypovolemic shock. D. compensatory stage of diabetic shock.

Correct Answer is C

Explanation

A. Initial stage of septic shock

Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.

B. Refractory stage of obstructive shock

Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.

C. Progressive stage of hypovolemic shock

The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).

D. Compensatory stage of diabetic shock

"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

Correct Answer is ["A","E"]

Explanation

Correct Answer is C

Explanation

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