When assessing a patient with altered level of consciousness, which of the following would the nurse assess first?
Respiratory status
Alertness
Motor response
Verbal response
The Correct Answer is A
Choice A: Respiratory status is the first priority, as it can affect the oxygenation and perfusion of the brain and other vital organs. The nurse should assess the rate, rhythm, depth, and quality of breathing, as well as the use of accessory muscles, chest expansion, and lung sounds.
Choice B: Alertness is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to open their eyes spontaneously or in response to stimuli, as well as their orientation to person, place, time, and situation.
Choice C: Motor response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to move their limbs voluntarily or in response to stimuli, as well as their muscle strength, tone, and coordination.
Choice D: Verbal response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to speak clearly and coherently, as well as their content and appropriateness of speech.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Fall risk assessment is important for patients with Parkinson's, as they may have impaired balance, gait, and coordination, as well as muscle stiffness and tremor, that can increase their risk of falling and injuring themselves¹.
Choice B: Swallowing assessment is important for patients with Parkinson's, as they may have difficulty chewing and swallowing due to reduced muscle control in the mouth and throat, which can lead to malnutrition, dehydration, and aspiration pneumonia¹.
Choice C: Skin assessment is important for patients with Parkinson's, as they may have reduced sweating and sebum production due to autonomic dysfunction, which can cause dry and cracked skin that is prone to infection¹.
Choice D: All of the above is correct, as all of these assessments are relevant for patients with Parkinson's.
Correct Answer is D
Explanation
Choice A: Sepsis is a serious infection that occurs when the body's immune system overreacts to an injury or illness. It can cause organ failure and death. People with spinal cord injury are more prone to sepsis because they may have impaired bladder and bowel function, skin breakdown, or reduced sensation that can lead to infections.
Choice B: Pulmonary embolism is a blockage of an artery in the lungs by a blood clot. It can cause chest pain, shortness of breath, and death. People with spinal cord injury are more at risk of pulmonary embolism because they may have reduced mobility, blood circulation, or breathing capacity that can promote blood clot formation.
Choice C: Pneumonia is an inflammation of the lungs caused by bacteria, viruses, or fungi. It can cause fever, cough, and difficulty breathing. People with spinal cord injury are more susceptible to pneumonia because they may have weakened cough reflex, impaired lung function, or aspiration of food or saliva into the lungs.
Choice D: All of the above are major causes of death related to spinal cord injury. They can occur separately or together and can be prevented or treated with proper medical care and lifestyle modifications.
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