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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Epinephrine 1 mg IV
Epinephrine is used for severe anaphylaxis. This reaction is more consistent with a mild allergic (febrile) transfusion reaction, which does not require epinephrine.

B. Acetaminophen 650 mg PO
Acetaminophen is used for febrile reactions but does not treat the allergic symptoms (itching, urticaria).

C. Diphenhydramine 50 mg IV
Diphenhydramine (Benadryl) is given to treat mild allergic transfusion reactions such as flushing, itching, and urticaria.

D. Furosemide 40 mg PO
Furosemide (Lasix) is given between blood transfusions to prevent fluid overload, not for allergic reactions.

A. monitoring for dysrhythmias B. monitoring for bleeding. C. adherence to their antihypertensive drugs D. preventing thrombus formation.

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.

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The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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