The nurse easily and quickly assesses changes in level of consciousness (eye opening, verbal responses motor response) using which neurological exams?
Glascow Coma Scale
NIH Stroke Scale
Romberg Test
Mini Mental Status Exam
The Correct Answer is A
A) Glasgow Coma Scale:
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool used to assess a patient's level of consciousness based on three criteria: eye opening, verbal response, and motor response. Each of these categories is scored, and the total score helps to determine the depth of the patient's consciousness. The GCS is commonly used to monitor changes in a patient's neurological status, especially after trauma, stroke, or other conditions that may impair brain function.
B) NIH Stroke Scale:
The NIH Stroke Scale (NIHSS) is used to assess the severity of stroke symptoms and includes measures such as facial droop, arm and leg motor function, speech, and language abilities. It is used specifically to evaluate stroke symptoms and is not designed for the rapid assessment of general consciousness like the Glasgow Coma Scale.
C) Romberg Test:
The Romberg Test is a test of balance that is performed by having the patient stand with their feet together, eyes closed, and observing for any swaying or loss of balance. It is used to evaluate proprioception and cerebellar function, not to assess the level of consciousness.
D) Mini Mental Status Exam:
The Mini-Mental Status Exam (MMSE) is a brief cognitive screening tool that assesses aspects of cognitive function such as orientation, attention, memory, language, and visuospatial skills. While the MMSE can provide insight into cognitive function, it does not focus on the specific assessment of consciousness level (eye opening, verbal response, motor response) as the GCS does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Be placed in isolation to prevent radiation exposure to others:
Radioactive iodine (I-131) is commonly used to treat thyroid cancer because it targets and destroys thyroid tissue, including any remaining cancerous cells. This treatment involves the administration of a radioactive substance that can be excreted through saliva, urine, and sweat. To minimize radiation exposure to others, patients are often placed in isolation, particularly in a hospital setting, for a period following administration.
B) Avoid consuming any food or fluids for 24 hours prior to the treatment:
While it’s essential for patients to follow specific instructions regarding food and fluid intake, such as avoiding certain foods or fluids that may interfere with absorption or increase the risk of side effects (like dairy products), the patient does not need to avoid all food and fluids for 24 hours after receiving radioactive iodine.
C) Avoid all physical activity for six weeks after the treatment:
While some precautions, such as avoiding close contact with others for a short period of time, may be necessary, avoiding physical activity for six weeks is not usually required. Patients may be advised to take it easy during the initial recovery phase, but they can typically resume normal activities once the initial isolation period is complete and their radiation exposure is below safety thresholds.
D) Discontinue all other medications for a week before treatment:
However, certain medications that affect thyroid function (such as thyroid hormones or antithyroid medications) may need to be adjusted or stopped before treatment to ensure the effectiveness of the radioactive iodine. The specifics would depend on the patient’s condition and the healthcare provider’s instructions.
Correct Answer is B
Explanation
A) Begins training to prepare to run a marathon next year:
This response is not characteristic of the stage of anger. Instead, this behavior suggests denial or possibly bargaining, as the client may be attempting to maintain a sense of normalcy or even hope in the face of a terminal illness like Amyotrophic Lateral Sclerosis (ALS).
B) Refuses to attend church and states that "his faith has failed him":
This statement reflects the anger stage of Kubler-Ross’s five stages of grief. During the anger stage, individuals often experience intense feelings of frustration, helplessness, and resentment about their situation. They may direct these emotions towards others, including higher powers or themselves. In this case, the client is expressing anger by blaming his circumstances and feeling abandoned by his faith, a common reaction when facing an irreversible condition like ALS.
C) Promises God to give up smoking if allowed to live until their children are married:
This behavior represents the bargaining stage of grief, not anger. In the bargaining phase, individuals may attempt to negotiate with a higher power or themselves, making promises or deals in exchange for a prolongation of life or a desired outcome. The client is trying to strike a "deal" by making promises for future behavior in exchange for a specific wish, reflecting bargaining rather than anger.
D) Gathers the family together in order to discuss what their last wishes are:
This scenario aligns more with the acceptance stage of grief. In the acceptance stage, individuals come to terms with their diagnosis and begin to make plans for the end of their life. The act of discussing last wishes indicates that the client is accepting the reality of their condition and preparing for what is to come.
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