The most reliable indicator of neurologic status is which of the following?
Level of consciousness (LOC)
Temperature
Blood pressure
Pulse rate
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Movement of the trachea toward the unaffected side indicates a possible tension pneumothorax, which is a life-threatening condition. This shift occurs due to the increased pressure on the affected side, pushing the trachea away. Immediate intervention is required.
Choice B rationale: Crepitus, or subcutaneous emphysema, can be a common finding around the chest tube insertion site. It indicates air leakage into the subcutaneous tissue but does not necessarily require immediate notification to the provider unless it is extensive or worsening.
Choice C rationale: Bubbling of the water in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning properly by allowing air to escape from the pleural space. This is a normal finding in pneumothorax management.
Choice D rationale: The visibility of eyelets on the chest tube indicates that the tube is in the correct position within the pleural space. If the eyelets are not visible, it means the tube is not functioning correctly, but this is not as urgent as a tracheal shift.
Correct Answer is D
Explanation
Choice A reason: While painful and red-tinged urination is a concern, it is not directly related to the intravenous pyelogram procedure.
Choice B reason: The end of the menstrual period is not relevant to the intravenous pyelogram procedure.
Choice C reason: Drinking fluids is generally encouraged but does not need to be reported unless it is restricted before the procedure.
Choice D reason: The client's allergy to shellfish is important to report because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause a reaction in people with shellfish allergies.
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