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

Dim vision.

Papilledema

Body temperature

Level of consciousness

Answer and Explanation

The Correct Answer is D

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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Correct Answer is C

Explanation

A. Tachycardia is more commonly associated with early stages of shock or compensation but is not a specific sign of increased ICP.
B. Amnesia may occur with a traumatic brain injury, but it is not a direct sign of increased ICP.
C. Restlessness or agitation is an early sign of increased ICP, as the brain becomes more impaired due to pressure, leading to confusion and changes in behavior.
D. Hypotension is not typically associated with increased ICP. In fact, as ICP rises, there may be compensatory mechanisms that maintain blood pressure, and in later stages, the blood pressure may rise.

A. Decrease environmental stimuli. B. Complete a vascular assessment. C. Administer an antipyretic. D. Assess the cranial nerves.

Correct Answer is A

Explanation

A. Decreasing environmental stimuli can help reduce the risk of seizures and further stress on the patient. This is especially important in cases of meningitis, as the patient may be more sensitive to light, sound, and touch.
B. A vascular assessment is important but not the next immediate action in this scenario.
C. Administering an antipyretic is important but not the priority action right after implementing droplet precautions.
D. Assessing cranial nerves may be necessary later in the assessment but is not the immediate next step.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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