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. 4+ edema is characterized by very deep pitting, where the indentation remains for an extended period (several minutes), indicating severe fluid accumulation in the tissue.
B. Deep pitting that lasts for a few minutes is more consistent with 2+ or 3+ edema, not the severe 4+ edema described.
C. Mild pitting with no perceptible swelling does not align with 4+ edema; this level of pitting suggests minimal fluid accumulation.
D. Moderate pitting where the indentation subsides rapidly is indicative of 2+ edema, not the profound swelling described as 4+ edema.
Correct Answer is B
Explanation
A. The Cowper gland, also known as the bulbourethral gland, secretes a clear, mucus-like pre-ejaculate to lubricate and neutralize urethral acidity.
B.The prostate gland secretes a thin, milky alkaline fluid that nourishes and protects sperm and enhances sperm viability.
C.The bulbourethral gland (Cowper gland) is responsible for producing a clear, mucus-like pre-ejaculatethat neutralizes the urethra.
D.The median sulcus refers to a groove or depression on the surface of an organ and is not associated with secretion in the reproductive system.
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