The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).
Which of the following findings should the nurse report to the practitioner immediately?
ability to swallow pureed foods
client reports mild headache
Weakness
Glasgow coma scale of 5
The Correct Answer is D
A. Ability to swallow pureed foods suggests some functional capacity and is not an immediate concern requiring immediate reporting.
B. A mild headache reported by the client might not indicate a critical issue requiring immediate reporting.
C. Weakness can be a concerning symptom, but the severity or extent of weakness needs further clarification before urgent reporting.
D. A Glasgow Coma Scale (GCS) score of 5 is indicative of severe impairment of consciousness, requiring immediate attention and further evaluation by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B. Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C. Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D. Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.
Correct Answer is ["B"]
Explanation
A. Stress can affect sexual performance, but it's not exclusively an internal factor. Stress can be caused by both internal and external factors.
B. Low testosterone levels are an internal factor that can significantly impact sexual performance in aging males. Testosterone decline is a natural part of aging and can affect libido and sexual function.
C. Substance use can affect sexual performance, but it's not solely an internal cause as it often involves external factors related to the intake of substances.
D. Lack of sleep affects overall health, but it can also be influenced by external factors and is not strictly an internal cause.
E. Chronic diseases such as diabetes, cardiovascular diseases, and others can have internal physiological effects that impact blood flow, nerve function, and overall health, contributing to declines in sexual performance later in life.
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