An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of following findings is the earliest indicator of the client's cerebral status?

Pupil response

Deep tendon reflexes

Muscle strength

Level of consciousness

Answer and Explanation

The Correct Answer is D

A. Pupil response:

Pupil response refers to the reaction of the pupils to light stimulus. The pupils should normally constrict when exposed to bright light and dilate in dim light. Changes in pupil size or reactivity can indicate alterations in neurological function. For example, unequal or non-reactive pupils (anisocoria or fixed pupils) can be indicative of dysfunction in the cranial nerves or brainstem. However, while pupil response is an important aspect of neurological assessment, it may not always be the earliest indicator of cerebral status changes.

B. Deep tendon reflexes:

Deep tendon reflexes are involuntary muscle contractions in response to stretching of a muscle tendon. These reflexes are assessed by tapping the tendon with a reflex hammer, eliciting a rapid and brief muscle contraction. Changes in deep tendon reflexes can provide information about the integrity of the peripheral nervous system and spinal cord. However, alterations in deep tendon reflexes may occur secondary to changes in cerebral function and are typically assessed along with other neurological signs.

C. Muscle strength:

Muscle strength refers to the force generated by muscles during voluntary movement. It is typically assessed by asking the client to perform specific movements against resistance or by testing the strength of individual muscle groups using standardized scales (e.g., Medical Research Council scale). Changes in muscle strength can occur due to neurological or musculoskeletal conditions. While weakness or paralysis can result from lesions affecting the upper motor neurons (e.g., strokes or spinal cord injuries), alterations in muscle strength may not always be the earliest indicator of cerebral status changes.

D. Level of consciousness:

The level of consciousness refers to the degree of awareness and alertness exhibited by the client. It is assessed by evaluating the client's responsiveness, orientation, and ability to follow commands. Changes in the level of consciousness, such as confusion, lethargy, stupor, or coma, can indicate alterations in cerebral function and are often the earliest indicators of neurological dysfunction. Assessing the level of consciousness is a critical component of neurological examination and helps guide further assessment and management of clients with suspected brain tumors or other neurological conditions.

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Correct Answer is C

Explanation

A.While monitoring for elevated blood pressure is important in identifying autonomic dysreflexia once it occurs, it does not prevent the condition. The nurse should focus on eliminating potential triggers, such as bladder distention or constipation, to prevent the occurrence.

B.Headaches are a symptom of autonomic dysreflexia, often related to severe hypertension. While treating the headache may alleviate discomfort, it does not address the underlying cause, nor does it prevent the onset of autonomic dysreflexia.

C.Bladder distention is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The nurse should ensure that the client's bladder is regularly emptied to prevent overdistention, which can stimulate the autonomic reflex and trigger AD.

D.Elevating the head is an intervention used during an episode of autonomic dysreflexia to help lower blood pressure and reduce symptoms. However, this action does not prevent the condition from occurring.

A. "It is too early to tell. When the spinal shock subsides, we will know more." B. "You should talk to your physician about things of that nature." C. "No. Significant recovery of function should occur in a few days." D. "Yes. In all likelihood, the paralysis is probably permanent."

Correct Answer is A

Explanation

A. "It is too early to tell. When the spinal shock subsides, we will know more."

This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.

B. "You should talk to your physician about things of that nature."

This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.

C. "No. Significant recovery of function should occur in a few days."

This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.

D. "Yes. In all likelihood, the paralysis is probably permanent."

This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.

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An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of following findings is the earliest indicator of the client's cerebral status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Correct Answer is C

Explanation

On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

Correct Answer is A

Explanation

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