A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?

Monro-Kellie hypothesis

Glasgow Coma Scale

Cranial nerve function

Mental status examination

Answer and Explanation

The Correct Answer is B

A. Monro-Kellie hypothesis: The Monro-Kellie hypothesis explains the relationship between the volumes of brain tissue, blood, and cerebrospinal fluid in the cranium, but it is not a diagnostic tool for assessing LOC.

B. Glasgow Coma Scale: The Glasgow Coma Scale (GCS) is a standardized tool used to assess a client's level of consciousness, particularly in cases of head injury. It evaluates eye opening, verbal response, and motor response.

C. Cranial nerve function: Cranial nerve assessment is important in evaluating neurological function, but it is not a comprehensive tool for gauging LOC.

D. Mental status examination: A mental status examination assesses cognitive functions, but the Glasgow Coma Scale is more appropriate for evaluating LOC in the context of head trauma.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Generalized pain: Generalized pain is not a typical early sign of deterioration following a hemorrhagic stroke.

B. Alteration in level of consciousness (LOC): An alteration in LOC is often the earliest and most sensitive sign of neurological deterioration in clients who have had a hemorrhagic stroke. This can indicate increased intracranial pressure or further bleeding.

C. Tonic-clonic seizures: While seizures can occur after a stroke, they are not typically the earliest sign of deterioration. Changes in LOC usually precede seizure activity.

D. Shortness of breath: Shortness of breath may indicate respiratory issues but is not directly related to early neurological deterioration following a stroke.

A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.

Correct Answer is D

Explanation

A. Elevate the head of the bed: Elevating the head of the bed is not the priority during a seizure. The primary concern is ensuring the client's safety by preventing injury.

B. Restrain the client's arms and legs: Restraining a client during a seizure is not advised, as it can cause injury. Instead, the focus should be on protecting the client from harm.

C. Place a tongue blade in the client's mouth: Placing anything in the client’s mouth during a seizure is contraindicated, as it can lead to airway obstruction or injury.

D. Take measures to prevent injury: The priority during a seizure is to protect the client from injury by ensuring a safe environment, such as padding the head and moving any dangerous objects away.

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

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Correct Answer is B

Explanation

A client is having a tonic-clonic seizure. What should the nurse do first?

Correct Answer is D

Explanation

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Building trust is especially critical to developing a therapeutic relationship with an anxious client. Which of the following interventions contributes to this trust?

A client with alcoholism has just completed a residential treatment program. What can this client reasonably expect?

The nurse is providing education via phone to a client who called stating that the newly prescribed imipramine (Tofranil) is not working as depression is still a problem. Which question is most important to ask first?

A client who is prescribed a tricyclic antidepressant is brought to the emergency department with a suspected overdose. Which would the nurse assess to support this suspicion? Select all that apply.

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

A psychiatric mental-health nurse is evaluating the treatment plan of an adult client diagnosed with schizophrenia disorder with aggressive behaviors. Which outcome of the client would demonstrate successful treatment?

A client with depression is admitted to an inpatient psychiatric unit. The nurse provides a unit orientation. While observing the client's unpacking, the nurse can expect the client to exhibit: