Nokea
The nurse is admitting a patient with a head injury who is acutely confused. Which of the following actions should the nurse take?
- A. Ask family members about the patient's health history.
- B. Ask leading questions to assist in obtaining health data.
- C. Wait until the patient is better oriented to ask questions.
- D. Obtain only the physiologic neurological assessment data.
Correct Answer: A
Rationale: When admitting a patient with confusion, the nurse should obtain health history information from others who have knowledge about the patient's health to obtain accurate data. Waiting until the patient is oriented or obtaining only physiological data will result in incomplete assessment data, this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.
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After reviewing a patient's cerebrospinal fluid (CSF) analysis, which of the following results is most important for the nurse to communicate to the health care provider?
- A. Specific gravity 1.007
- B. Protein 6.5 g/L
- C. White blood cell (WBC) count 5 x 10^6/L
- D. Glucose 2.5 mmol/L
Correct Answer: B
Rationale: The protein level is high. The specific gravity, WBCs, and glucose values are normal.
Which a patient who has peripheral nerve dysfunction? of the following information about an older-adult patient is most important for the admitting nurse to report to the patient's health care provider?
- A. Triceps reflex response graded at 1/5
- B. Recent unintended weight loss of 9.1 kg
- C. Patient complaint of persistent difficulty in falling asleep
- D. Orthostatic drop in systolic blood pressure of 10 mm Hg
Correct Answer: B
Rationale: Although changes in appetite are normal with aging, a 9.1 kg weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.
The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which of the following nursing diagnoses is appropriate?
- A. Acute pain related to physical injury agent (hyper-reflexia and spasm)
- B. Risk for falls as evidenced by impaired mobility
- C. Risk for autonomic dysreflexia as evidenced by spasm
- D. Ineffective thermoregulation related to inactivity
Correct Answer: B
Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for autonomic dysreflexia, thermoregulation, or hyper-reflexia.
Which of the following actions should the nurse implement to assess the functioning of the trigeminal and facial nerves (CN V and VII) in a patient?
- A. Apply a cotton wisp strand to the cornea.
- B. Have the patient read a magazine or book.
- C. Shine a bright light into the patient's pupil.
- D. Check for unilateral drooping of the eyelids.
Correct Answer: A
Rationale: The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
Which of the following equipment should the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction?
- A. Electrodes
- B. Tuning fork
- C. Reflex hammer
- D. Goniometer
Correct Answer: B
Rationale: Vibration sense is tested by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and joint range of motion.