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NurseDive Free Nursing Practice Question
After performing a neurological assessment, the student nurse shares the following findings with the primary nurse: Visual fields full to confrontation with Intact extraocular movements. No nystagmus, midline protrusion of tongue, and negative Romberg test. Which of the following will the primary nurse tell the student nurse to document?
A. Abnormal visual fields, abnormal motor assessment
This choice is incorrect because the visual fields and motor assessment are normal, not abnormal.
B. Normal neurological assessment findings
This choice is correct because the findings indicate that the visual fields, extraocularmovements, cranial nerves IX and XII (glossopharyngeal and hypoglossal), and vestibular function are normal.
C. Normal visual but abnormal cranial nerves IXII
This choice is incorrect because the cranial nerves IXII are not assessed in this scenario, only IX and XII are.
D. Normal visual fields, abnormal motor assessment
This choice is incorrect because the motor assessment is normal, not abnormal.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
A. The client needs total nursing care.
Correct. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma.The client would need total nursing care and close monitoring of vital signs, neurologic status, and intracranial pressure.
B. The client has a stable neurologic status
Incorrect. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would not have a stable neurologic status and would be at risk forcomplications such as increased intracranial pressure, seizures, and brain herniation.
C. The client is alert and oriented.
Incorrect. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would not be alert and oriented, but unresponsive to most stimuli.
D. The client has a mild brain injury but requires extensive care
Incorrect. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would not have a mild brain injury, but a lifethreatening condition that requires intensive care.
When caring for the client with Alzheimer's disease, which of the following are appropriate items to include in the client's room?
A. complete darkness at night.
Incorrect. Complete darkness at night can increase confusion and agitation in clients with Alzheimer's disease. The room should have adequate lighting and a night light to help orient the client and prevent falls.
B. suction equipment
Incorrect. Suction equipment is not necessary for clients with Alzheimer's disease unless they have respiratory problems or difficulty swallowing. Suction equipment can be noisy and frightening for clients with cognitive impairment and should be avoided unless indicated.
C. walker or cane
Incorrect. A walker or cane may be helpful for clients with Alzheimer's disease who have mobility issues, but it is not an essential item to include in the room. A walker or cane can also pose a tripping hazard or be used as a weapon by agitated clients.
D. clocks, calendar, family photos
Correct. Clocks, calendar, family photos are appropriate items to include in the room of a client with Alzheimer's disease. They can help the client maintain orientation to time, place, and person, and provide comfort and familiarity.
Full Explanation
A. Incorrect. Complete darkness at night can increase confusion and agitation in clients with Alzheimer's disease. The room should have adequate lighting and a night light to help orient the client and prevent falls.
B. Incorrect. Suction equipment is not necessary for clients with Alzheimer's disease unless they have respiratory problems or difficulty swallowing. Suction equipment can be noisy and frightening for clients with cognitive impairment and should be avoided unless indicated.
C. Incorrect. A walker or cane may be helpful for clients with Alzheimer's disease who have mobility issues, but it is not an essential item to include in the room. A walker or cane can also pose a tripping hazard or be used as a weapon by agitated clients.
D. Correct. Clocks, calendar, family photos are appropriate items to include in the room of a client with Alzheimer's disease. They can help the client maintain orientation to time, place, and person, and provide comfort and familiarity.
A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.
A. Assess vital signs
Assess vital signs. This is not the best first action because the client has a very low Glasgow Coma score (6 out of 15), which indicates a severe brain injury and a high risk of respiratory failure. The priority is to secure the airway and provide oxygenation.
B. Ask the client about medications
Ask the client about medications. This is not the best first action because the client is unlikely to be able to respond verbally due to the low level of consciousness and possible brain damage. The nurse should obtain the medication history from other sources, such as family or paramedics.
C. Ask the client what he recalls from the accident
Ask the client what he recalls from the accident. This is not the best first action because the client is not alert or oriented and may not have any memory of the accident due to the braininjury. The nurse should focus on assessing and stabilizing the client's physical condition.
D. Prepare the client for mechanical ventilation
Prepare the client for mechanical ventilation. This is the best first action because the client has a very low Glasgow Coma score and may lose the ability to breathe spontaneously or maintain adequate oxygenation. The nurse should prepare the equipment and medications for intubation and mechanical ventilation, and notify the physician.