Which are the nurse's priority concepts during assessment of a client with a neurologic
problem? Select all that apply.
A. Fluid and electrolyte balance
B. Sensory perception
C. Perfusion
D. Cognition
E. Mobility
F. Acid-base balance - ANSB. Sensory perception
D. Cognition
E. Mobility
Which functions will the nurse assess as cerebellar when checking a client's neurologic status?
Select all that apply.
A. Keeping an extremity from overshooting an intended target
B. Moving from one skilled movement to another in an orderly sequence
C. Controlling involuntary movement
D. Maintaining equilibrium
E. Predicting distance or gauging the speed with which one is approaching an object
F. Controlling awakeness and awareness - ANSA. Keeping an extremity from overshooting an
intended target
B. Moving from one skilled movement to another in an orderly sequence
D. Maintaining equilibrium
E. Predicting distance or gauging the speed with which one is approaching an object
Which interventions will the nurse employ to prevent harm when providing care for an older
client who is at risk for falls related to altered balance and decreased coordination? Select all
that apply.
A. Instruct the client to move slowly when changing positions.
B. Encourage the client not to get out of bed unless it is really necessary.
C. Advise the client to hold on to handrails when ambulating.
D. Raise all four siderails and place the bed in the lowest position.
E. Request that a family member or a sitter stay with the client at all times.
F. Assess the need for an ambulatory aid, such as a cane or walker - ANSA. Instruct the client
to move slowly when changing positions.
C. Advise the client to hold on to handrails when ambulating.
F. Assess the need for an ambulatory aid, such as a cane or walker
, Which assessment techniques are most relevant for the nurse to use when performing a
neurologic examination for cognition on a client? Select all that apply.
A. Give the client a simple command and observe how he or she reacts.
B. Observe the client walking across the room, turning, and walking back.
C. Ask the client for his or her name, date of birth, today's date, time, and location.
D. Observe how well the client follows a topic or attends to an activity.
E. Show the client a familiar object and ask him or her to state its name and purpose.
F. Note whether the client responds rapidly and relevantly to questions - ANSA. Give the client a
simple command and observe how he or she reacts.
C. Ask the client for his or her name, date of birth, today's date, time, and location.
D. Observe how well the client follows a topic or attends to an activity.
E. Show the client a familiar object and ask him or her to state its name and purpose.
F. Note whether the client responds rapidly and relevantly to questions
Which findings must be reported to the health care provider immediately when the nurse
assesses several clients using the Glasgow Coma Scale (GCS)? Select all that apply.
A. A client's GCS decreases by 3 points
B. A client arouses with supraorbital pressure
C. A client has fixed nonreactive pupils
D. A client has extreme flexion of the upper extremities
E. A client asks for pain medication often before the drug is due
F. A client is suddenly unable to recall where he or she is now - ANSA. A client's GCS
decreases by 3 points
C. A client has fixed nonreactive pupils
D. A client has extreme flexion of the upper extremities
F. A client is suddenly unable to recall where he or she is now
Which stimuli are recommended for the nurse to apply when a client has not responded to a
loud voice or gentle shaking during Glasgow Coma Scale (GSC) assessment? Select all that
apply.
A. Supraorbital pressure by placing a thumb under the orbital rim in the middle of the eyebrow
and pushing upward
B. Alternating sharp pin prick with cotton ball on several spots over the hands and feet
C. Trapezius muscle squeeze by pinching or squeezing the trapezius muscle located at the
angle of the shoulder and neck muscle
D. Mandibular pressure to the jaw by using the index and middle fingers to pinch the lower jaw
E. Sternal rub by making a fist and rubbing/ twisting the knuckles against the sternum
F. Continuous application of pain for 45 seconds to determine if the client will withdraw from the
pain - ANSA. Supraorbital pressure by placing a thumb under the orbital rim in the middle of the
eyebrow and pushing upward
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