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 C

Explanation

A. While literacy is an important consideration, the focus should be on understanding the patient's cultural background to ensure appropriate care and address any specific needs related to their ethnicity and traditions.
B. A financial history may be relevant but does not directly relate to the patient's immediate care needs regarding abdominal pain.
C. Cultural assessment is essential to understand the patient's values, beliefs, and preferences in healthcare, particularly in a diverse population, to ensure culturally competent care.
D. Psychological history could be useful in some cases, but it is secondary to cultural considerations in a patient with abdominal pain.

A. pump up the cuff until no sound is heard and then let the air out. B. stop midway and begin to inflate again. C. make sure the bell of the stethoscope is placed firmly over the artery. D. continue to listen until the cuff is deflated.

Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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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

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Naxlex Comprehensive Predictor Exams

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

Correct Answer is C

Explanation

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Correct Answer is D

Explanation

A 52-year-old patient presents with malaise, fatigue, chest congestion, and a chronic cough. While collecting assessment data, an important question to ask is

If a patient's blood pressure measures 146/92 on the left arm and 138/84 on the right arm, what would you do?

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

A very pertinent part of the physical examination on a patient with back pain is

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:

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:

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:

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)