vSim Health Assessment | Edith Johnson (Neurological Assessment)

Mrs. Jacobson was prescribed raloxifene hydrochloride 18 months ago. She is concerned the dizziness she felt just before she fell is a result of the medication. How does the nurse best address her concerns?

Assure her that dizziness is not one of the recognized side effects of that medication

To assess an adult patient suspected of experiencing increased intracranial pressure (ICP), the nurse will implement which intervention?

Check pupillary activity

A patient has reported dizziness that has been associated with orthostatic hypotension. What information will the nurse provide to the patient that is directly associated with this condition?

Dehydration can be a trigger for the dizziness. Rationale: Orthostatic hypotension is often associated with a lack of sufficient circulating blood.

The nurse's patient, Edith Jacobson, is being monitored after a fall that results in a fractured hip. Her initial assessment included a Glasgow Coma Scale assessment that showed she had no observable deficiencies involving consciousness. Following the provider's orders she is being monitored with the administration of the Glasgow Coma Scale every 4 hours. When the current assessment indicates that the patient has scored a 14, what will the nurse's initial response be?

Document the latest Glasgow Scale results as 14

Which statement by a patient would cause the nurse to suspect that a pattern of falling exists?

I fell twice when I was visiting my daughter 2 months ago.

What behavior would the nurse document as lethargy r/t Mrs. Jacobson's LOC?

Remains awake only long enough to answer questions

An older adult patient has fallen and sustained a bruise to the forehead. Although there appears to be no significant injury, the family is concerned when the provider orders a Mini-Cog assessment and asks, "Why are you testing her memory and mental abilities?" Which explanation best meets the family's expressed needs?

Your mother's fall may have hurt the frontal lobe of her brain. That is the part that controls memory, reasoning, and judgment.

An older patient reports feeling dizzy right before falling. Which action by the nurse indicates an understanding of how dizziness can be triggered? (Select all that apply.)

a. Ask, "Had you been taking any nonprescription medications before the fall?" b. Review the patient's medical history for previous head injuries c. Assess the patient's blood pressure

Which nursing actions demonstrate an understanding of the components required when conducting the objective portion of a neurologic assessment? (Select all that apply.)

a. Evaluate cranial nerve XI function by asking the patient to shrug the shoulders d. Test for tactile discrimination using a door key Rationale: A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, and reflexes. The mental status exam is conducted first to assess the patient's ability to provide valid subjective information, not to minimize anxiety The Romberg test evaluates balance, not coordination. A reflex hammer is used to elicit deep tendon reflexes, not superficial responses.

An older adult patient is being assessed for potential fall risks. Which statements by the patient would the nurse identify as risk factors? (Select all that apply.)

a. I've started to have some trouble getting to the bathroom in time. c. I celebrated my 81st birthday last month. d. My cataract surgery is scheduled in 6 weeks. e. I'm less depressed since I've moved in with my daughter. Rationale: Advanced age (over 80), vision deficits, depression, and incontinence are personal risk factors for falls. Neither medication is typically associated with an increase for falls. Using more than four prescription medications is considered a risk factor.

Which nursing actions are associated with conducting a Glasgow Coma Scale assessment on a patient who has fallen and sustained a possible brain injury? (Select all that apply.)

a. Request that the patient squeeze the nurse's hand c. Ask the patient to identify where they are d. Observe which stimuli cause the patient to open their eyes Rationale: The Glasgow Coma Scale focuses on eye opening response, verbal response, and motor response. The assessment of pain or V/S is not included in the screening.

An older adult is being prepared for discharge to her daughter's home after completing rehabilitation following surgery to repair a hip fracture. What information will the nurse include in discharge teaching to best help minimize the patient's risk for falls? (Select all that apply.)

a. Use a walking device to help with proper balance b. Turn on lights at night when getting out of bed to go to the bathroom d. Sit down and rest when feeling dizzy e. Drink enough fluids to keep urine pale and clear (lowers orthostatic hypotension)

Which nursing actions would be effective when managing an older adult patient's risk for injury r/t falling? (Select all that apply.)

b. Present the patient with fluids regularly throughout the day c. Offer to take the patient to the toilet every 2-3 hours d. Encourage the patient to wear prescription glasses e. Measure the patient's BP both when sitting and upon standing