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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.
B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.
C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.
D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.
Correct Answer is C
Explanation
A. the client feels vulnerable to stigma: While stigma can prevent clients from reporting suicidal thoughts, this is not the primary reason for initiating a suicide risk assessment.
B. young adults tend to use manipulation: Assuming that young adults manipulate their symptoms is not a valid reason for initiating a suicide risk assessment. This response is inappropriate and can harm the therapeutic relationship.
C. this is a standard assessment: A suicide risk assessment is a standard part of care for clients with depression and thoughts of hopelessness, even if suicidal ideation is not explicitly reported. This ensures comprehensive evaluation and appropriate intervention.
D. the client lives with extended family: The living situation may influence the support system, but it is not the primary reason to initiate a suicide risk assessment.
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