🧠 Neurological Assessment
A patient who fell at home reports a headache and blurred vision. Which neurological assessment should the nurse perform first?
Level of consciousness
Which assessment finding best indicates decreased tissue perfusion: warm skin, urine output 15 mL/hr, pulse 78/min, or BP 120/76 mm Hg?
Urine output 15 mL/hr.
What assessment finding is the most accurate indicator of fluid volume changes?
Daily weight.
A patient complains of shortness of breath. Which assessment should the nurse obtain immediately?
Oxygen saturation
A white blood cell count of 15,000/mm³ most likely indicates what condition?
Infection or inflammation.
A patient suddenly develops left-sided weakness and difficulty speaking. What is the nurse's priority action?
Activate the stroke response process/notify the provider immediately.
A client becomes pale, dizzy, and tachycardic after surgery. What complication should the nurse suspect first?
Hemorrhage/hypovolemia.
A patient gains 4 pounds in 48 hours and develops crackles in the lungs. What imbalance is occurring?
Fluid volume excess.
Which early sign may indicate acute respiratory distress syndrome?
Mild dyspnea and fine crackles.
Which assessment finding is most concerning in a postoperative wound?
Purulent drainage with warmth and swelling
A patient with a head injury develops a blood pressure of 190/100 mm Hg and a heart rate of 48/min. What complication should the nurse suspect?
Increased intracranial pressure.
A patient's heart rate rises from 80 to 120/min while blood pressure drops from 128/80 to 88/50 mm Hg. What does this trend suggest?
Decreased perfusion or impending shock.
Which electrolyte imbalance should the nurse suspect when a patient develops muscle spasms during blood pressure cuff inflation?
Hypocalcemia.
A patient receiving opioids has a respiratory rate of 7/min. What is the priority assessment?
Airway and respiratory status.
A patient with pneumonia becomes increasingly confused and restless. What should the nurse suspect?
Clinical deterioration/sepsis.
During a neuro assessment, one pupil is 6 mm and sluggish while the other is 3 mm and reactive. Why is this finding concerning?
It may indicate neurologic deterioration or increased intracranial pressure.
Which finding suggests improvement after treatment for hypovolemia?
Increased urine output and stable blood pressure.
A patient receiving gastric suction has a potassium level of 2.8 mEq/L. Why is this finding concerning?
Increased risk for dysrhythmias.
After receiving naloxone, which finding indicates improvement?
Increased respiratory rate and alertness.
Which vital sign trend is most consistent with worsening sepsis?
Rising temperature and heart rate with decreasing blood pressure
A nurse observes decorticate posturing in a patient following a traumatic brain injury. What does this indicate?
Significant brain dysfunction requiring immediate intervention.
A patient with GI bleeding develops confusion, cool clammy skin, and hypotension. What is the priority nursing intervention?
Establish IV access and begin fluid resuscitation.
Which laboratory result requires immediate follow-up: Sodium 139, Potassium 6.0, Glucose 110, or Hemoglobin 13?
Potassium 6.0 mEq/L.
A patient develops wheezing, facial swelling, and hypotension after receiving an IV antibiotic. What emergency should the nurse recognize?
Anaphylaxis.
What is the priority action when sepsis is suspected?
Notify the provider and initiate the sepsis protocol.