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 B
Explanation
A. Provide the daughter and client with nutritional counseling.
While nutrition is important, assessing for abuse is the priority.
B. Interview the client alone and assess for abuse.
The client’s reluctance and daughter’s interruptions suggest potential elder abuse.
C. Take the history from the daughter due to the client’s confusion.
The client should be interviewed alone first.
D. Request a psychiatric evaluation.
Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.
Correct Answer is ["C","D","E"]
Explanation
A. Color of conjunctiva
While assessing for signs of perfusion is important, conjunctival color is not a primary assessment for norepinephrine administration. Perfusion is better assessed through blood pressure, heart rate, capillary refill, and urine output.
B. Deep tendon reflexes
Norepinephrine primarily affects vascular tone and cardiac output. Deep tendon reflexes are not a priority assessment for this medication.
C. IV Insertion site
Norepinephrine is a vasopressor, and extravasation can cause severe tissue necrosis. Frequent monitoring of the IV site is necessary to prevent complications.
D. Blood pressure and heart rate
Norepinephrine increases blood pressure and heart rate through vasoconstriction. Continuous monitoring is required to assess for excessive hypertension, tachycardia, or inadequate response to therapy.
E. Hourly urine output
Urine output is an essential indicator of organ perfusion. Since norepinephrine is used to maintain adequate blood pressure and perfusion in septic shock, monitoring urine output helps assess the effectiveness of treatment.
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