The nurse is preparing to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment?
1. ECG
2. Brainstem functioning
3. Reflexes
4. Level of consciousness
4
Rationale 1: An electrocardiogram is not a part of an hourly neurologic assessment.
Rationale 2: On occasion, the nurse might be involved with assessing brainstem functioning; however, this is not a part of an hourly neurologic assessment.
Rationale 3: Reflexes are not a part of an hourly neurologic assessment.
Rationale 4: Components of an hourly neurologic assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning.
You might also like to view...
Which professional characteristic implies that the nurse respects the client's ability to understand and recognizes the client's right to know the details of the plan of care?
1. Positive regard. 2. Empathy. 3. Genuineness. 4. Concreteness.
Locsin argues that technological competency can and should displace the perception of caring in nursing
Indicate whether this statement is true or false.
Bromhidrosis can be assessed by:
a. palpation. b. percussion. c. auscultation. d. olfaction.
In assessing family structure, it is important for the nurse to recognize that:
1. An individual may experience many different family structures over a lifetime 2. The variations in family structure are becoming less common 3. The traditional nuclear family is the only appropriate family structure 4. Although there is great variation among family structures, there is little variation within particular family structures