The most reliable indicator of neurologic status is which of the following?

Level of consciousness (LOC)

Temperature

Blood pressure

Pulse rate

Answer and Explanation

The Correct Answer is A

Choice A reason: Level of consciousness is the most basic and sensitive indicator of altered brain function and is considered the most reliable indicator of neurologic status.

Choice B reason: Temperature is not a direct indicator of neurologic status and does not change as rapidly in response to neurologic events.

Choice C reason: Blood pressure can be aﬀected by neurologic changes, but it is not as sensitive or specific as the level of consciousness.

Choice D reason: Pulse rate is not a direct indicator of neurologic status and can be inﬂuenced by a variety of non- neurologic factors.

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Correct Answer is C

Explanation

Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.

Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.

Choice C reason: Ineﬀective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.

Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.

A. Stable ECG rhythm B. Ability to verbalize causes and eﬀects of CHD/CAD C. Adequate relief of pain D. Compliance with prescribed bedrest

Correct Answer is C

Explanation

Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.

Choice B reason : Educating the patient about the causes and eﬀects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.

Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.

Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.

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The most reliable indicator of neurologic status is which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following nursing diagnoses (nursing problem) would be of highest priority for the patient hospitalized for a bone marrow transplant to treat relapse of acute myelocytic leukemia?

Correct Answer is C

Explanation

In planning care for a patient with acute myocardial infarction (AMI), which of the following should the nurse identify as the highest priority goal of care?

Correct Answer is C

Explanation

The most reliable indicator of neurologic status is which of the following?

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