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
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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Related Questions
Correct Answer is C
Explanation
A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.
Correct Answer is A
Explanation
A. Chewing food on the unaffected side helps to prevent triggering pain episodes in the affected side of the face, which is critical for managing trigeminal neuralgia effectively.
B. While maintaining oral hygiene is important, the timing of brushing teeth is less critical than managing pain during eating. Brushing teeth should be done gently to avoid pain but is not specifically prioritized over other interventions.
C. Avoiding an electric razor is not relevant to managing trigeminal neuralgia pain; it relates more to safety and comfort in shaving rather than pain management.
D. Food should not be served hot or cold as extreme temperatures can trigger pain in trigeminal neuralgia patients; it's better to serve food at a moderate temperature.
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