The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of

Answer and Explanation

The Correct Answer is D

A.   A score of 7 would indicate a much lower level of consciousness and require urgent intervention.
B.   A score of 12 would indicate some level of impairment, with the patient not fully alert or responsive.
C.   A score of 10 would indicate some level of impairment, with the patient not fully alert or responsive.
D.   A score of 15 on the Glasgow Coma Scale indicates full consciousness and normal neurological function. It is the highest possible score, reflecting a patient who is awake, aware, and able to follow commands.

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Correct Answer is A

Explanation

A. Gathering information from a family member can help obtain a more accurate history, especially when the patient has difficulty recalling specific details due to age-related memory changes.
B. Omitting the interview would lead to incomplete information and potentially delay appropriate care.
C. Repeating the questions may be helpful but may not always yield reliable data if the patient struggles to remember key details.
D. While forgetfulness can be normal with aging, healthcare providers need to ensure accurate information is collected to provide optimal care.

A. check the patient's record to determine his baseline blood pressure. B. notify the charge nurse of the hypotension. C. check medications that might be the cause of the irregularity. D. notify the doctor of the bradycardia.

Correct Answer is A

Explanation

A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.

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The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

Correct Answer is A

Explanation

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Correct Answer is A

Explanation

When performing an initial assessment on a patient, which piece of information is of highest priority?

The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

If dehydration occurs, the blood pressure will

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 170/90 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is