A patient is exhibiting an altered level of consciousness (LOC) due to a blunt force trauma to the head, causing Increased Intracranial Pressure (ICP)
When assessing level of consciousness in this patient, the priority nursing evaluation would be based on which of the following?
A) Monro-Kellie doctrine
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status exam
Ans: B
Feedback: Level of consciousness (LOC) is a sensitive indicator of neurologic function based on the criteria in the Glasgow Coma Scale. It includes eye opening, verbal response, and motor response. Refer to Chart 63-4. The Monro-Kellie doctrine states that because of the limited space for expansion within the skull an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status exam would be part of the neurological examination for this patient but would not be the priority in evaluating level of consciousness.
You might also like to view...
Important considerations are to be followed when administering medications to prevent errors. Shortcuts should not be taken, and principles should be adhered to. One of these principles is:
a. placing an unlabeled syringe on the medication cart. b. following the six rights of medication administration. c. leaving a medication with the patient only when family is there. d. always charting medications before the end of shift.
A nurse is describing the advantages and disadvantages associated with tamoxifen therapy as a means of breast cancer prevention. The nurse would identify that the drug has a beneficial effect on which of the following?
A) Bone mineral density B) High density lipoprotein levels C) Risk for endometrial cancer D) Cataract formation
The nurse is assessing a client with a severe left pleural effusion. Which of the following findings are expected? Standard Text: Select all that apply
1. Absent breath sounds on the left side 2. Tracheal shift to the right 3. Hyperresonance upon percussion. 4. Bronchial breath sounds of the right side 5. Pleural friction rub auscultated.
Preceding a stress test, the following lab work might include
A. CBC and differential to differentiate ischemic heart disease from anemia B. Liver enzymes to rule out underlying gall bladder disease C. Thyroid studies to rule out hyperthyroidism D. A & C only