The practical nurse (PN) is monitoring a client's neurologic status following a closed head injury. Which assessments should the PN include? Select all that apply.

Vital sign measurement.

Carotid pulse rate.

Consciousness level.

Jugular vein distention.

Pupillary reactions.

Answer and Explanation

Correct Answer : A,C,E

A. Vital sign measurement: Monitoring temperature, pulse, respirations, and blood pressure provides critical information about intracranial pressure changes and neurologic stability. Alterations such as irregular respirations or widening pulse pressure can signal deterioration.

B. Carotid pulse rate: Palpating the carotid pulse is not necessary for neurologic assessment and can be unsafe if excessive pressure is applied, as it may decrease cerebral perfusion. Pulse rate and rhythm can be assessed through other safer means.

C. Consciousness level: Assessing level of consciousness using tools like the Glasgow Coma Scale is one of the most sensitive indicators of neurologic change. Any alteration in alertness, orientation, or response indicates possible increased intracranial pressure or worsening brain injury.

D. Jugular vein distention: This assessment is more relevant for evaluating cardiac function or fluid overload rather than neurologic status. It provides little information about brain injury or intracranial dynamics.

E. Pupillary reactions: Pupillary size, equality, and response to light reflect brainstem function and cranial nerve integrity. Changes such as unequal or sluggish pupils may signal pressure on cranial nerves or worsening neurologic condition.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Advise the UAP to wash hands before providing further care: While reminding the UAP to wash hands before assisting another client is important, the immediate concern is that the UAP may have left the client’s room without performing proper hand hygiene, which risks cross-contamination.

B. Determine if the UAP was wearing gloves when providing care: The use of gloves does not replace the need for proper hand hygiene. Even if gloves were worn, hands must still be washed after glove removal to prevent the spread of pathogens.

C. Instruct the UAP to return to the client's room to wash hands: Directing the UAP to perform hand hygiene immediately after client contact ensures compliance with standard precautions and protects other clients from contamination.

D. Remind the UAP to use an alcohol-based hand rub regularly: Regular use of alcohol-based sanitizer is encouraged, but in this case, the PN should ensure immediate corrective action rather than provide a general reminder. The focus must be on stopping the current breach of infection control.

A. I don't have any use for those who say this disease is going to win B. I've found the support I need from my faith and family. C. I think I've had this disease for a long time, but the doctor did not find it. D. I understand that this is a disease that occurs mostly in older men.

Correct Answer is B

Explanation

A. "I don't have any use for those who say this disease is going to win": This statement reflects anger or resistance, which is common in earlier stages of grief and adjustment, rather than acceptance of prognosis.

B. "I've found the support I need from my faith and family": Seeking and acknowledging support demonstrates that the client has processed emotions, adapted to the diagnosis, and reached a level of acceptance, allowing for coping and meaningful engagement with life.

C. "I think I've had this disease for a long time, but the doctor did not find it": This statement reflects confusion or disbelief, indicating the client is still processing the diagnosis rather than accepting it.

D. "I understand that this is a disease that occurs mostly in older men": While factual understanding shows knowledge about the disease, it does not necessarily reflect personal acceptance of prognosis or emotional adjustment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The practical nurse (PN) is monitoring a client's neurologic status following a closed head injury. Which assessments should the PN include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) who is leaving a client. Which immediate action should the PN take?

Correct Answer is C

Explanation

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

Correct Answer is B

Explanation

A client who is receiving a statin medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN takes priority?

The practical nurse (PN) plans to reinforce the proper use of a cane to an older client who is recovering from a stroke. When providing information to the client how to correctly use this assistive device, where should the PN reinforce with the client to place the cane?

The practical nurse (PN) is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body?

The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the PN monitor? (Select all that apply.)

When providing oral care to an unconscious client who is a mouth-breather and does not swallow, which action is most important for the practical nurse (PN) to implement?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

The practical nurse (PN) evaluates a client 30 minutes after the initial administration of a new prescription. Which client response requires immediate action by the PN?

The practical nurse (PN) is working with a newly hired PN on a medical surgical unit. Which action performed by the newly hired PN requires intervention by the PN?