Neuro Assessment - Priority Data Collection The nurse...

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Priority Data Collection The nurse begins the admission assessment with the collection of priority assessment data. 1. Which assessment should the nurse complete first after the client's arrival on the unit? A) Sensory function. INCORRECT Sensory function is an important component of a neurological assessment, but is not the highest priority assessment at this time. B) Orientation. INCORRECT Orientation is an important component of a neurological assessment, but another assessment is of higher priority. C) Speech patterns. INCORRECT Speech patterns are an important component of a neurological assessment, but are not the highest priority assessment at this time. D) Level of consciousness. CORRECT In planning care, a top priority is client safety. Assessment of the client's level of consciousness is essential to determine the care needed to ensure client safety. Points Earned: 1.0/1.0 Correct Answer(s): D 2. Based on Ms. Davidson's recent history of loss of consciousness and falling, what additional assessment takes priority? CORRECT Both hypotension and bradycardia may cause loss of consciousness, so these vital signs should be assessed immediately. The nurse measures Ms. Davidson's vital signs and assesses her level of consciousness, then proceeds to interview the client. INCORRECT
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The pedal pulse volume is unlikely to provide essential data related to the client's recent loss of consciousness. INCORRECT Altered deep tendon reflexes are of less priority upon initial assessment than other assessment data. INCORRECT This assessment of sensory function is of less priority upon initial assessment than other assessment data. Points Earned: 1.0/1.0 Correct Answer(s): A Client Interview Ms. Davidson reports that she did not experience a spinning sensation prior to passing out. 3. To determine if the client experienced vertigo before she lost consciousness, what question should the nurse ask Ms. Davidson? Before you passed out, did you A) Feel light-headed or weak? INCORRECT This question will not elicit information specific to vertigo. B) Experience a spinning sensation? CORRECT Vertigo is defined as a spinning sensation. C) Notice any tingling or numbness? INCORRECT This question will elicit information related to parasthesia, an abnormal sensation. D) Have trouble moving your arms or legs? INCORRECT This question will not elicit information specific to vertigo. Points Earned: 0.0/1.0 Correct Answer(s): B
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