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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Wear compression stockings daily." is not specifically related to preventing diabetic complications of the eyes and kidneys.
B. "Examine your feet carefully every day." is important for preventing diabetic foot ulcers but is not directly related to preventing retinopathy and nephropathy.
C. Maintaining stable blood glucose levels is the most effective way to prevent complications like retinopathy and nephropathy in clients with diabetes mellitus. Consistently high blood glucose levels can lead to damage to blood vessels in the eyes and kidneys.
D. "Have an eye examination once per year." is important, but maintaining stable blood glucose levels is the most effective long-term prevention strategy.
Correct Answer is D
Explanation
A. CN V (Trigeminal nerve) is responsible for sensation in the face and motor function for chewing, not eye movement or pupil constriction.
B. CN VIII (Vestibulocochlear nerve) deals with hearing and balance, not eye function.
C. CN IV (Trochlear nerve) controls eye movement, but it does not typically affect the pupil in this way.
D. Cranial nerve III (Oculomotor nerve) controls most eye movements and pupil constriction. A fixed and dilated pupil typically indicates damage to CN III, which may be due to nerve compression, often from increased intracranial pressure or herniation.
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