The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?

Encourage frequent ambulation

Maintain foot in a dependent position.

Apply warm, moist heat

Wrap the foot snugly in the blanket

Answer and Explanation

The Correct Answer is C

A.   Ambulation may worsen the condition as it could increase swelling or spread infection.
B.   This may increase swelling and should generally be avoided in cellulitis.
C.   This helps to improve circulation and reduce swelling in cellulitis.
D.   Wrapping the foot tightly could exacerbate swelling and discomfort.

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Correct Answer is C

Explanation

A. The client is unable to make vocal sound would be more consistent with a verbal response score of 1.
B. The client is unconscious is not correct, as a GCS score of 13 indicates they are not in a deep coma.
C. A GCS score of 3 for eye opening indicates that the patient responds to verbal stimuli (eye-opening to speech), a score of 5 for best verbal response indicates they can speak but not necessarily coherently, and a 5 for best motor response indicates purposeful movement, like following commands.
D. The client can follow simple motor commands would typically reflect a motor response score of 6, not

A. Dim vision. B. Papilledema C. Body temperature D. Level of consciousness

Correct Answer is D

Explanation

A. Dim vision could be a sign of many conditions but is not the first indicator the nurse should assess for neurologic status.

B. Papilledema (swelling of the optic disc) is a late sign of increased intracranial pressure and is not immediately available on assessment.
C. Body temperature is important but not as directly related to the neurological status as LOC.
D. The level of consciousness (LOC) is one of the most important initial indicators of a patient's neurologic status, as it helps assess brain function and the severity of potential neurological injury. A decrease in LOC can indicate significant brain injury or dysfunction.

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The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is C

Explanation

when assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first?

Correct Answer is D

Explanation

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