HA Chapter 22

B. verbal response, eye opening, and motor response.

Use of the GCS provides relatively objective assessment of LOC. The three functions assessed are:

A. pupil reaction, orientation, and sensation.

B. verbal response, eye opening, and motor response.

C. eye opening, motor response, and sensation.

D. verbal response, pupil reaction, and motor response.

A. Decreased LOC and sluggish pupil

The patient with a head injury and increasing ICP is likely to have which assessment findings?

A. Decreased LOC and sluggish pupil

B. Left-sided weakness and facial droop

C. Right ptosis and right-sided loss of vision

D. Dilated left pupil and receptive aphasia

D. Weakness in the left arm

The chart states that a 62-year-old person has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following?

A. Tremors on the left side of the face

B. Tremors on the right side of the face

C. Weakness in the right arm

D. Weakness in the left arm

B. High BP, diet high in fat, and smoking

The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke:

A. Low BP, lack of exercise, and diet high in fat

B. High BP, diet high in fat, and smoking

C. Diet high in fat, smoking, and walking five times weekly

D. Obesity, swimming five times weekly, high BP

D. Babinski sign

If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following?

A. Hyporeflexia

B. Normal plantar reflex

C. Cushing response

D. Babinski sign

A. legs.

A 26-year-old person was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the:

A. legs.

B. abdomen.

C. chest.

D. arms.

B. risk for injury.

A patient in a nursing home was admitted with a diagnosis of dementia. They started a fire because they were cooking at home and forgot that they left a pan on the stove. The nursing diagnosis that is of highest priority is:

A. ineffective brain tissue perfusion.

B. risk for injury.

C. acute confusion.

D. impaired memory.

B. bowel/bladder incontinence.

While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for:

A. dizziness.

B. bowel/bladder incontinence.

C. difficulty swallowing.

D. arm weakness.

B. the whisper test.

A 47-year-old patient states they are having vertigo and some difficulty with balance. The nurse should assess:

A. accommodation.

B. the whisper test.

C. shoulder strength.

D. soft touch.

B. Altered mentation

Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemispheres?

A. An enlarging pupil that is sluggishly reactive to light

B. Altered mentation

C. Widening pulse pressure with bradycardia

D. Reflex posturing of extremities