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The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. In which manner are these results reported?
- A. As a sum of the scores of the four categories
- B. As part of the Glasgow Coma Scale
- C. As individual scores in each category
- D. As progressive scores during a 24-hour period
Correct Answer: C
Rationale: The FOUR score coma scale assesses the patient in four categories: eye response, brainstem reflexes, motor response, and respiration. The scores are reported as individual scores in each category. It is frequently done in conjunction with or as an alternative to the Glasgow Coma Scale, not part of it.
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The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. Which position is most appropriate for the patient?
- A. Neck placed in a neutral position.
- B. Head raised slightly with hips flexed.
- C. Supine in gravity neutral position.
- D. Turn on right side with head elevated.
Correct Answer: A
Rationale: The patient is experiencing increased intracranial pressure. To assist with reducing the intracranial pressure, place the patient's neck in a neutral position (not flexed or extended) to promote venous drainage.
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
- A. Do you have any sensations of pins and needles in your feet?'
- B. Does the pain radiate from your back into your legs?'
- C. Can you describe the sensations you are having?'
- D. Do you ever have any nausea or dizziness?'
Correct Answer: C
Rationale: For patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms.
Which sign is the cardinal sign of increased intracranial pressure in a patient who has sustained a brain injury?
- A. Pupil changes
- B. Ipsilateral paralysis
- C. Vomiting
- D. Decrease in the level of consciousness
Correct Answer: D
Rationale: Collection of objective data includes a change in level of consciousness. A change in the level of consciousness is the earliest sign of increased intracranial pressure.
Which food should the person who experiences migraine headaches avoid?
- A. Yogurt
- B. Caffeine
- C. Beef
- D. Pears
- E. Marinated foods
- F. Milk
Correct Answer: A,B,E
Rationale: Some foods may cause or worsen headaches. Foods that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork.
What are surgical navigational systems?
- A. Computerized devices that guide the surgeon
- B. A set of detailed anatomic maps pinpointing specific areas of the brain
- C. A written set of progressive processes for the resection of small brain tumors
- D. The use of radioactive materials to pinpoint small tumors of the brain
Correct Answer: A
Rationale: Surgical navigational systems are computerized devices that guide the surgeon and make possible the resection of tumors that were once thought to be inoperable.