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 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.
Correct Answer is C
Explanation
A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.
B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.
C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.
D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.
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