A
A change in level of consciousness is the earliest and most sensitive indication of a
change in intracranial processing. This is assessed with the
... [Show More] Glasgow Coma Scale
(GCS), which assesses eye opening and verbal and motor response. The inability to
focus may indicate a change, but it is not one of the earliest indicators or a component
of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that
disappear with maturation. These reflexes may reappear with frontal lobe dysfunction
and may be tested for with a suspected brain injury, so it would be the reappearance of
primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but
they are not one of the earliest indicators or a component of the GCS. - ANS-The
earliest and most sensitive assessment finding that would indicate an alteration in
intracranial regulation would be:
A) change in level of consciousness.
B) unequal pupil size.
C) loss of primitive reflexes.
D) inability to focus visually.
A
Albumin, prealbumin, and lymphocyte counts all give information related to nutritional
status. The albumin and lymphocyte counts given are normal. The white blood cell
count is not directly related to nutritional status. The prealbumin count is low and is a
more specific indicator of nutritional status than is the albumin count. This puts the client
at risk for impaired wound healing, so the nurse should request a dietary consult. - ANSA client with a pressure ulcer has the following laboratory values: white blood count
8000/mm3, prealbumin 15.2 mg/dL, albumin 4.2 mg/dL, and lymphocyte count
2000/mm3. Which action by the nurse is most appropriate?
A) Request a dietary consult.
B) Assess the client's vital signs.
C) Document the findings.
D) Place the client in isolation.
A
Although most people with heart failure will have failure that progresses from left to
right, it is possible to have left-sided failure alone for a short period. It is also possible to
have heart failure that progresses from right to left. Causes of left ventricular failure
include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.
- ANS-The nurse is assessing clients on a cardiac unit. Which client does the nurse
assess most carefully for developing left-sided heart failure?A) Middle-aged woman with aortic stenosis
B) Older woman who smokes cigarettes daily
C) Older man who has had a myocardial infarction
D) Middle-aged man with pulmonary hypertension [Show Less]