When assessing a patient with altered level of consciousness, which of the following would the nurse assess first?
Respiratory status
Alertness
Motor response
Verbal response
The Correct Answer is A
Choice A: Respiratory status is the first priority, as it can affect the oxygenation and perfusion of the brain and other vital organs. The nurse should assess the rate, rhythm, depth, and quality of breathing, as well as the use of accessory muscles, chest expansion, and lung sounds.
Choice B: Alertness is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to open their eyes spontaneously or in response to stimuli, as well as their orientation to person, place, time, and situation.
Choice C: Motor response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to move their limbs voluntarily or in response to stimuli, as well as their muscle strength, tone, and coordination.
Choice D: Verbal response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to speak clearly and coherently, as well as their content and appropriateness of speech.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Antihypertensive medication lowers blood pressure, which reduces the risk of stroke caused by high blood pressure or hypertension.
Choice B: Anti-cholesterol medication lowers the level of cholesterol in the blood, which reduces the risk of stroke caused by atherosclerosis or plaque buildup in the arteries.
Choice C: Antiplatelet medication prevents blood clots from forming, which reduces the risk of stroke caused by ischemia or blockage of blood flow to the brain.
Choice D: All of the above medications are used to treat and prevent strokes, as they address different risk factors and causes of stroke.
Correct Answer is C
Explanation
Choice A: Altered level of consciousness is not a sign/symptom of cerebral spinal fluid leakage, but rather a sign/symptom of increased intracranial pressure or brain injury.
Choice B: Painful headache is not a sign/symptom of cerebral spinal fluid leakage, but rather a sign/symptom of meningitis or sinusitis.
Choice C: Salty taste in their mouth, postnasal drip or clear fluid draining from the nose is a sign/symptom of cerebral spinal fluid leakage, as it indicates that the fluid is escaping from the brain or spinal cord through a tear or hole in the meninges or skull.
Choice D: All of the above is not correct, as only choice C is a sign/symptom of cerebral spinal fluid leakage.
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