After performing a neurological assessment, the student nurse shares the following findings with the primary nurse: Visual fields full to confrontation with Intact extraocular movements. No nystagmus, midline protrusion of tongue, and negative Romberg test. Which of the following will the primary nurse tell the student nurse to document?

Abnormal visual fields, abnormal motor assessment

Normal neurological assessment findings

Normal visual but abnormal cranial nerves IXII

Normal visual fields, abnormal motor assessment

Answer and Explanation

The Correct Answer is B

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Correct Answer is A

Explanation

A. A GCS score of 3 for eye opening indicates that the client opens their eyes in response to speech. This accurately reflects the client's level of responsiveness.

B. A GCS score of 5 for motor response indicates that the client localizes pain or can follow simple motor commands. However, this does not fully encapsulate the most appropriate conclusion, given the specific GCS score for eye opening.

C. A total GCS score of 13 (3 for eye opening, 5 for verbal response, and 5 for motor response) suggests mild impairment, not unconsciousness. Unconsciousness is typically indicated by a GCS score of 8 or below.

D. A GCS score of 5 for verbal response indicates the client is oriented and can respond verbally, so they are capable of making vocal sounds.

A. Encourage the use of the wide grip utensils. B. Remind the client to look for food on the left side of the tray C. Provide a nonskid mat to alleviate plate movement D. Encourage the client to use his right hand when feeding himself

Correct Answer is B

No explanation

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Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is A

Explanation

A nurse caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?

Correct Answer is B

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?

A client suspected of having a stroke is scheduled to have an angiogram. Which of the following is a priority action for the nurse?

A client has a history of atrial fibrillation. Which of the following is the nurse likely to see on the clients medication history to prevent stroke?

A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?