Which of the following findings in your assessment would be the most reliable way to determine your patient's neurological status?

BP of 90/65

Cranial nerve testing

PERRLA

Change in level of consciousness

Answer and Explanation

The Correct Answer is D

A. BP of 90/65 is incorrect because blood pressure is a vital sign that can be influenced by many systemic factors. While hypotension or hypertension may affect cerebral perfusion, it is not the most reliable indicator of neurological status.

B. Cranial nerve testing is incorrect because cranial nerve assessment provides useful information about specific neurological functions, but it does not give a global view of the patient’s overall neurological status.

C. PERRLA (pupils equal, round, reactive to light and accommodation) is incorrect because pupil response is an important component of neurological assessment, but changes can be delayed or affected by medications, eye trauma, or other factors. It does not reflect overall brain function as reliably as level of consciousness.

D. Change in level of consciousness is correct because level of consciousness is the most sensitive and reliable indicator of neurological status. Alterations in consciousness often precede other signs of neurological deterioration, making it a key parameter in assessing patients with increased intracranial pressure or other acute neurological conditions. Nurses use tools like the Glasgow Coma Scale to quantify changes in consciousness and detect early deterioration.

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Correct Answer is ["A","C","D"]

Explanation

A. Kussmaul’s respirations are correct because DKA causes metabolic acidosis due to the accumulation of ketone bodies. The body compensates by increasing the depth and rate of respirations to blow off carbon dioxide, resulting in deep, rapid breathing known as Kussmaul respirations.

B. Dysuria is incorrect because painful or difficult urination is not a characteristic symptom of DKA. While patients may have polyuria due to osmotic diuresis from hyperglycemia, dysuria is more suggestive of a urinary tract infection.

C. “Fruity” breath is correct because acetone, a byproduct of ketone metabolism, is exhaled through the lungs. This gives the breath a sweet or fruity odor and is a classic finding in patients with DKA.

D. Ketonuria is correct because insulin deficiency leads to fat breakdown and ketone production. Excess ketones are excreted in the urine, making ketonuria a key diagnostic and expected finding in DKA.

E. Glucose levels below 100 are incorrect because DKA is characterized by significant hyperglycemia, typically with blood glucose levels well above normal, often greater than 250 mg/dL.

A. That the patient will be alert and oriented B. The patient will be comatose C. The patient will likely have a UTI D. That the patient will be vomiting

Correct Answer is B

Explanation

A. That the patient will be alert and oriented is incorrect because a GCS of 8 indicates severe impairment of consciousness, not alertness. Patients who are alert and oriented typically have a GCS of 13–15.

B. The patient will be comatose is correct because a GCS score of 8 or lessis generally considered coma or severe brain injury. This indicates significant neurological impairment, and the patient is likely unable to respond appropriately to verbal or painful stimuli. Immediate interventions often focus on airway protection, stabilization, and rapid neurological assessment.

C. The patient will likely have a UTI is incorrect because a urinary tract infection is not related to the GCS score. While a UTI can cause confusion in older adults, it does not directly correlate with a GCS of 8 in trauma or acute neurological events.

D. That the patient will be vomiting is incorrect because vomiting may occur in patients with elevated intracranial pressure or head trauma, but it is not a defining feature of a GCS of 8. The key concern is level of consciousnessand neurological status.

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Which of the following findings in your assessment would be the most reliable way to determine your patient's neurological status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are the primary RN caring for patient in Diabetic Ketoacidosis (DKA). Which of the following symptoms would you expect to see in this patient?

Correct Answer is ["A","C","D"]

Explanation

You are working in the ED and get call from the paramedics to tell you they are bringing in a patient. The paramedics tell you that the patient has a Glasgow coma scale (GCS) of 8. What should you expect when the patient arrives to the ED?

Correct Answer is B

Explanation

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