The nurse is caring for a client with a neurological deficit. In assessing the client, the nurse will utilize the standard Glasgow Coma Scale. What will the nurse be assessing on this patient? Select all that apply.

Thought process.

Verbal response.

Motor response.

Eye response.

Cognitive ability.

Answer and Explanation

Correct Answer : B,C,D

The Glasgow Coma Scale (GCS) is a tool used to assess a patient's level of consciousness following a traumatic brain injury. It is based on three categories: eye-opening, verbal response, and motor response. The tool scores a patient from 3 to 15, with 15 being the best possible score. A score of 8 or less indicates a severe brain injury. The tool does not assess thought process or cognitive ability.

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Correct Answer is ["A","B","C"]

Explanation

Polydipsia, Polyuria, and Polyphagia. These are the three P's of hyperglycemia, which are common symptoms of diabetes. Polydipsia refers to excessive thirst, polyuria refers to excessive urination, and polyphagia refers to excessive hunger. These symptoms are caused by high blood glucose levels in the body.

Polyhydramniosrefers to excessive amniotic fluid in the uterus during pregnancy, and it is not a sign or symptom of diabetes.

A. Palpation. B. Inspection. C. Auscultation. D. Percussion.

Correct Answer is B

Explanation

Inspection, followed by Auscultation, Percussion, and Palpation. Inspection assesses for abdominal contour, symmetry, any visible masses, scars or other abnormalities. Auscultation assesses bowel sounds, and Percussion assesses for any areas of tenderness, and to determine the presence of fluid, gas or masses. Palpation assesses for any masses, areas of tenderness, organ size or other abnormalities. This is the order that allows the nurse to assess the abdomen systematically and accurately.

A: Palpation comes last because it can stimulate bowel sounds, which can make the nurse miss some of the sounds while auscultating.

C: Auscultation must be done before percussion and palpation to prevent altering bowel sounds.

D: Percussion comes before palpation to avoid altering the underlying structures of the abdomen.

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The nurse is caring for a client with a neurological deficit. In assessing the client, the nurse will utilize the standard Glasgow Coma Scale. What will the nurse be assessing on this patient? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing instructor is facilitating a discussion with a group of nursing students about common signs and symptoms of diabetes which include the 3 P's. What are the three P's of hyperglycemia? (SATA).

Correct Answer is ["A","B","C"]

Explanation

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)

Correct Answer is B

Explanation

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?

The nurse in the clinic is assessing a young child brought in by the parents with symptoms of meningitis. The nurse will assess for dropdown by asking the child to flex the chin to the neck.

A client, who is recovering from bariatric surgery, is eating from a po [portable commode]. Nursing assessment is of greatest concern in the immediate postoperative period for which of the following?

Which nursing instruction is correct to provide the client following a barium enema?

The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

The nurse is caring for a young woman who is struggling with weight loss issues without apparent physical cause. Which is the most likely nursing assessment for this nutritional disorder in which normal body weight is not maintained?

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The nurse is caring for a group of breast cancer survivors postmastectomy. When developing a list of instructions of points to avoid, which point is highlighted?