The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What will the nurse do next?
Re-assess in 15 minutes
Ask the patient to open eyes on command
Document the findings
Notify the physician
The Correct Answer is C
A) Re-assess in 15 minutes: While regular assessments are important in a neurological evaluation, if the Glasgow Coma Scale (GCS) score is 15, indicating the patient is fully alert and oriented, there may not be an immediate need to re-assess so soon unless the patient's condition changes.
B) Ask the patient to open eyes on command: If the GCS score is already determined to be 15, this indicates that the patient is responsive and capable of opening their eyes spontaneously. Asking the patient to open their eyes is unnecessary in this context since the score already reflects full responsiveness.
C) Document the findings: Documenting the GCS score of 15 is crucial as it establishes a baseline for the patient’s neurological status. This documentation is essential for ongoing assessments and monitoring, providing a record of the patient’s condition at this moment.
D) Notify the physician: Notifying the physician is not required for a GCS score of 15, as this score indicates a normal level of consciousness. Communication with the physician would be warranted only if there were changes in the patient's condition or a lower GCS score observed.
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Correct Answer is A
Explanation
A) Idiopathic neuropathy has no known cause: This statement is accurate, as idiopathic neuropathy refers to nerve damage for which no specific cause can be identified despite thorough investigation. The term "idiopathic" literally means "of unknown origin," indicating that the underlying mechanism remains unclear.
B) Idiopathic neuropathy is hereditary in nature: While some neuropathies can be hereditary, idiopathic neuropathy itself is not classified as hereditary since it lacks a defined genetic cause. Hereditary neuropathies are specific types that have a genetic basis.
C) Idiopathic neuropathy is caused by nutritional deficits: Nutritional deficits can lead to various types of neuropathy, but idiopathic neuropathy specifically is characterized by the absence of a known cause. Therefore, attributing it to nutritional deficits would be incorrect.
D) Idiopathic neuropathy is caused by disease or illness: While certain diseases can cause neuropathy, the key characteristic of idiopathic neuropathy is that no specific disease or illness has been identified as the cause. This differentiates it from other neuropathies that are secondary to identifiable conditions.
Correct Answer is A
Explanation
A) No discomfort: When palpating the sinuses, the expected finding is that there should be no discomfort. Healthy sinuses typically do not cause pain or tenderness during palpation, indicating that they are clear and not inflamed or infected.
B) Lumps less than 1 centimeter: While lumps may be found in various areas of the body, the presence of lumps in the sinus area during palpation is not a typical finding and may indicate an abnormality or concern that would require further evaluation.
C) Painful sensation behind the eyes: A painful sensation behind the eyes can indicate sinusitis or other sinus issues. It is not an expected finding during a normal examination of the sinuses, as healthy sinuses should not cause discomfort.
D) Heavy pressure: Heavy pressure is often a symptom associated with sinusitis or sinus congestion, but it is not an expected finding during a routine palpation of the sinuses. Healthy sinuses should not feel heavy or pressured during examination.