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

Assessing pupils for reactivity, equality, symmetry, and accommodation

Obtaining vital signs every four hours while hospitalized

Performing serial Glasgow Coma Scales throughout hospitalization

Performing a Mini Mental Status Exam at admission and discharge

Answer and Explanation

The Correct Answer is C

A. Assessing pupils is important, but it provides only partial information about the overall neurologic status and does not give a comprehensive picture of improvement or deterioration.
B. Vital signs can indicate some changes in condition but are not specific to neurologic status and do not provide detailed insight into cognitive or motor function.
C. Performing serial Glasgow Coma Scales allows for a standardized and objective assessment of a patient's level of consciousness, motor responses, and verbal responses over time, making it the most effective method to evaluate neurologic status.
D. The Mini Mental Status Exam provides useful information about cognitive function but may not capture acute changes in neurologic status as effectively as the Glasgow Coma Scale.

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Correct Answer is B

Explanation

A. Requesting antidepressant medication may be appropriate later, but it does not address the immediate need for emotional support and communication.
B. Encouraging the client to verbalize feelings about their diagnosis provides an opportunity for the client to express their concerns and emotions, fostering a therapeutic relationship and aiding in emotional processing.
C. While explaining improved prognosis can provide hope, it may minimize the client’s feelings of fear and uncertainty and could be perceived as dismissive.
D. Allowing time for reflection is important, but it should be balanced with the need for communication and support to prevent isolation.

A. contribute to the medical diagnosis of the client. B. provide a baseline assessment against which to evaluate changes in function. C. plan care to protect the client from falls/injury. D. anticipate other neurologic deficits that may arise.

Correct Answer is C

Explanation

A. Contributing to the medical diagnosis is a secondary goal for nursing care. The nurse's primary role is to ensure patient safety and prevent complications such as falls, which are more likely in patients with sensory and motor impairments.
B. While establishing a baseline for future comparison is important, it is not the most immediate concern. The nurse's priority is preventing falls and injury related to the impairment.
C. The priority in this case is to protect the client from falls or injury, as impaired motor and sensory function in the lower extremities increases the risk for accidents. Preventing injury will guide the development of the care plan, such as implementing fall precautions.
D. Anticipating other neurologic deficits is valuable but not the most urgent concern compared to protecting the client from the immediate risk of falls.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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