when assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first?
Dim vision.
Papilledema
Body temperature
Level of consciousness
The Correct Answer is D
A. Dim vision could be a sign of many conditions but is not the first indicator the nurse should assess for neurologic status.
B. Papilledema (swelling of the optic disc) is a late sign of increased intracranial pressure and is not immediately available on assessment.
C. Body temperature is important but not as directly related to the neurological status as LOC.
D. The level of consciousness (LOC) is one of the most important initial indicators of a patient's neurologic status, as it helps assess brain function and the severity of potential neurological injury. A decrease in LOC can indicate significant brain injury or dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Increased Intracranial Pressure (ICP)
Based on the patient’s clinical presentation, which includes a fall, slurred speech, weak cough reflex, restlessness, and a slight headache, the patient is at risk for increased intracranial pressure (ICP). The history of falling from a ladder could suggest a possible head injury, and the changes in speech and restlessness could be early signs of increasing ICP. The presence of a laceration on the left temple may also indicate a traumatic brain injury, which is a key risk factor for increased ICP.
Actions to Take:
- Apply oxygen via cannula at 2 L/min
Oxygen is critical for brain tissue oxygenation, especially in patients with possible head injuries and ICP. The patient's oxygen saturation is 90% on room air, which is slightly low and requires supplementation to maintain adequate oxygen levels and reduce the risk of hypoxia, which can exacerbate increased ICP.
- Elevate the head of the bed to 45 degrees
Elevating the head of the bed to 30-45 degrees can help improve venous drainage from the brain, thus reducing the risk of increased ICP. Positioning the patient in this way also helps reduce pressure on the brain and enhances cerebral perfusion.
Parameters to Monitor:
- Level of consciousness (LOC)
Changes in the patient's level of consciousness are a key indicator of worsening ICP. The nurse should assess the patient’s alertness, orientation, and any deterioration in cognitive function or responsiveness. The patient's current orientation level is X2, meaning they are only oriented to person and place, which may signal a developing problem.
- Vital signs
Monitoring vital signs, especially blood pressure, heart rate, and respiratory rate, is crucial in assessing the patient's neurological status. Changes in blood pressure (especially widening pulse pressure) or abnormal respiratory patterns can be early indicators of increased ICP. In particular, the patient's blood pressure (152/59) suggests a possible increased risk of ICP, with the systolic value elevated but the diastolic pressure relatively low. This could be a compensatory response to ICP or another issue.
Correct Answer is C
Explanation
A. Thrombotic stroke typically presents with gradual symptom onset, not the sudden headache and vomiting seen here.
B. Embolic stroke is associated with symptoms that appear suddenly and usually do not present with vomiting or seizures.
C. A hemorrhagic stroke is characterized by the sudden onset of a severe headache, vomiting, altered mental status, and sometimes seizures, which are all present in this patient. The high blood pressure and fever may indicate a hemorrhage in the brain or an associated infection.
D. Transient ischemic attack (TIA) presents with temporary neurological deficits and does not cause persistent symptoms like a seizure or vomiting.
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