The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?
Performing a mini mental status exam at admission and discharge
Performing serial Glasgow Coma Scale exams during hospitalization
Assessing pupils for reactivity, equality, symmetry and accommodation
Obtaining vital signs every four hours while hospitalized
The Correct Answer is B
A. Mini mental status exam at admission and discharge
Useful for cognitive function but not for acute changes.
B. Performing serial Glasgow Coma Scale exams
The GCS is the best tool for tracking changes in neurologic status over time.
C. Assessing pupils for reactivity, equality, symmetry, and accommodation
Important but not comprehensive.
D. Obtaining vital signs every four hours
Useful but does not specifically assess neurologic function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Monitoring for dysrhythmias
While cardiovascular health is important, dysrhythmias are not a primary concern in a small abdominal aortic aneurysm.
B. Monitoring for bleeding
While aneurysms can rupture, a small aneurysm is managed medically with blood pressure control, making bleeding less of an immediate concern.
C. Adherence to their antihypertensive drugs
Hypertension increases pressure on the aneurysm, increasing the risk of expansion and rupture. Strict adherence to antihypertensive medications is essential for preventing complications.
D. Preventing thrombus formation
While thrombus formation can occur in large aneurysms, it is not the primary focus in a small, medically managed aneurysm.
Correct Answer is A
Explanation
A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.
B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.
C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.
D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.
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