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. Decreased pedal pulses B. Hypertension C. Peripheral edema D. Diarrhea

Correct Answer is B

Explanation

A. Decreased pedal pulses:

Decreased pedal pulses are not typically associated with increased intracranial pressure. Instead, they may indicate peripheral vascular disease or reduced perfusion to the lower extremities. Monitoring peripheral pulses is important for assessing circulation but is not directly related to intracranial pressure changes.

B. Hypertension:

Hypertension can be a manifestation of increased intracranial pressure. The body may respond to elevated intracranial pressure by increasing blood pressure to maintain cerebral perfusion pressure. However, hypertension alone is not specific to increased ICP and can have various causes.

C. Peripheral edema:

Peripheral edema is not a typical manifestation of increased intracranial pressure. It may occur in conditions such as heart failure or renal dysfunction but is not directly related to intracranial pressure changes following a craniotomy.

D. Diarrhea:

Diarrhea is not a common manifestation of increased intracranial pressure. Increased ICP is more likely to manifest with symptoms such as headache, nausea, vomiting, altered level of consciousness, and focal neurological deficits.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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