Which data should be included in a routine neurological nursing assessment of a patient who has experienced a head injury?
a. Vital signs, lung sounds, and pedal pulses
b. Glasgow Coma Scale, pupil response, and vital signs
c. Range of motion, deep tendon reflexes, and capillary refill
d. Romberg test, Babinski reflex, and cranial nerve assessment
ANS: B
Assessment of neurological status minimally includes Glasgow Coma Scale score, pupil responses, muscle strength, and vital signs. Additional assessment of body systems is important but is not part of a neurological assessment. Romberg, Babinski, and cranial nerve assessment is more advanced and not routine.
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