The nurse is preparing to assess a patient with a head injury. Which data should the nurse include in this routine neurological nursing assessment?
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. A. C. Additional assessment of body systems are important but are not part of a neurological assessment. D. Romberg, Babinski, and cranial nerve assessment is more advanced and not routine.
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What can the nurse provide that allows the client a positive forward progression in the treatment process?
A) A therapeutic relationship B) Alternative activities to thoughts of self-injury C) A safe and trusting environment D) A sense of power and self-control
Which of the following structures of the ear equalizes pressure between the outer and middle ear?
a. eustachian tube c. semicircular canal b. fluid-filled cochlea d. tympanic membrane
What is your primary nursing goal at this time?
What will be an ideal response?
A client is newly diagnosed with heart failure. Which interventions should the nurse prepare to provide this client? Select all that apply
1. Bed rest 2. Elevate legs 3. Oxygen therapy 4. Fluid restriction 5. Low sodium diet