The nurse begins the admission assessment with the collection of priority assessment data that is immediately entered into her personal digital assistant (PDA.)
Which assessment should the nurse complete first after the client’s arrival on the unit?
(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.)
(Both hypertension and bradycardia may cause loss of consciousness, so these vital signs should be assessed immediately.)
To determine if the client experienced vertigo before she lost conciousness, what question should the nurse ask Ms. Davidson? Before you passed out, did you….
(Vertigo is defined as a spinning sensation.)
(This action demonstrates caring and also enables the nurse to obtain a more complete history related to the onset of the client’s symptoms.)
Before continuing the interview and assessment, the nurse enters the following initial data collected into her personal digital assistant (PDA):
Ms. Davidson demonstrates difficulty speaking and she previously reported feeling weak, passing out, and falling at home. Her vital signs are currently T 97F, BP 140/88, P 92 and R 18.
What terminology should accurately be included in the nurse’s documentation?
Syncope is sudden loss of strength or temporary loss of consciousness, which the client described as “passing out.”
(Aphasia should be assessed to determine if the client has lost the ability to comprehend information (receptive aphasia) or the ability to express onself (expressive aphasia) most commonly, the client experiences both, referred to as global aphasia.)
(Mental Status Exam)
While continuing the client interview, the nurse assesses the client’s mental status. As the interview continues, Ms. Davidson occasionally struggles to choose and form words, but seems comfortable and relaxed. The nurse provides a quiet, calm environment, allowing the client ample time to respond to the interview questions.
Ms. Davidson asks the nurse what her room number is, stating she needs to let her daughter know where she is.
Which assessment by the nurse accurately reflects the client’s statement?
(The client’s statement that she needs to notify her daughter that she is in the hospital indicates she is oriented to her situation. Lack of knowledge of her room number does not reflect disorientation or memory loss.)
(This action provides information related to the client’s recent memory. The nurse should ask questions with verifiable answers to ensure the client does not make up responses.)
Which interview data provides the nurse with information related to the client’s judgment?
(Indication of good judgement.)
After completing the interview and mental status exam, the nurse tests Ms. Davidson’s cranial nerves.
In checking Ms. Davidson’s pupillary response to light, the nurse first measures the size of the pupils. Each pupil is approximately 4mm. What action should the nurse take in response to this finding?
(Before checking the pupillary response to light, the nurse should first observe the size and shape of the pupils, observing for symmetry. The normal pupil size is 3 to 5mm, so the nurse should next observe and compare the shape of the pupils.)
After the nurse asks the client to close both eyes what is the next action the nurse should take?
(The nurse begins by asking the client to close both eyes. This allows the pupils to dilate. The nurse next holds the penlight to the side of the eye, so it is ready as soon as the client opens her eyes.)
While the client performs these tasks, what should the nurse do?
(The nurse observes for symmetric movement when the client smiles, frowns, or shows her teeth. This assessment provides data related to the function of the facial nerve, cranial nerve VII.)
(The nurse should test the client’s ability to shrug her shoulders against resistance with equal strength bilaterally.)
The nurse continues the neurological assessment by assessing motor function.
Since Ms. Davidson is lying in bed, which action should the nurse take to observe small muscle movement and coordination?
To assess upper extremity muscle strength, the nurse stands facing the client and holds out both hands toward the client. The nurse asks the client to grip 2 of the nurse’s fingers with 1 hand and 2 fingers with the other.
What instructions should the nurse provide next?
(When performing a hand grip test, the nurse asks the client to squeeze the nurse’s fingers with both hands simultaneously, so that the nurse can compare muscle strength bilaterally.)
What additional assessment should the nurse perform to validate the finding of unilateral upper extremity weakness?
(A palmar drift test is used to assess upper extremity weakness. The client is asked to hold up both arms with the palms up and eyes closed for 10 to 20 seconds. The weak arm will “drift” downward.)
After validating the finding of left-sided upper extremity weakness, the nurse next assesses Ms. Davidson’s sensory function.
The nurse uses a tuning fork to evaluate what sensory function?
(The client’s ability to sense vibration is assessed by placing a vibrating tuning fork on a bony surface.)
(Stereognosis, the ability to recognize objects by touch, should be assessed by placing a familiar object in the client’s hand. A tuning fork is not a familiar object to many people, so the nurse should replace the fork with a more familiar object, such as a comb.)
The nurse continues the neurological assessment by evaluating Ms. Davidson’s deep tendon reflexes (DTRs.)
The nurse begins by testing the client’s biceps reflex. With the client’s forearm resting on the nurse’s forearm and the nurse’s thumb over the biceps tendon, what action should the nurse take next to test the client’s biceps reflex?
(With the client’s forearm slightly flexed and relaxed, the nurse should strike the thumb with the pointed end of the reflex hammer to elicit a response.)
(The client’s response is normal and should be documented as a 2+ response.)
Shortly after completing the admission assessment, the nurse returns to the client’s room and notes a change in her condition. Ms. Davidson is slurring all her words. Further assessment reveals that Ms. Davidson is no longer able to move her left arm and leg, and within a few minutes no longer responds to the nurse’s questions. The nurse quickly assesses the client’s level of consciousness by checking for a response to varying stimuli.
What stimuli should the nurse use first to attempt to elicit a response from the patient?
(The nurse should begin with the least amount of stimulus and progress to the greatest amount of stimulus, observing the amount of stimulus needed to evoke a response by the patient.)
What data should the nurse obtain to complete the GCS rating? (Select all that apply.)
Ms. Davidson’s daughter Sylvia has arrived and the nurse explains that her mother’s condition has worsened. Sylvia cries, and tells the nurse that her mother had often told her that she had lived a full, long life, and did not want any extraordinary measures in the event of a serious illness.
The nurse assesses Ms. Davidson’s end of life wishes.
In assessing the client’s end of life wishes, the nurse remembers that Ms. Davidson’s husband is deceased. it is most important for the nurse to communicate with which person? The client’s….
(This person has been designated by the client to make health care decisions if the client is unable to do so.)
To confirm the verbal information regarding Ms. Davidson’s end of life wishes, the nurse plans to review the client’s living will.
What additional information related to end of life wishes is most important for the nurse to assess?
(It’s essential for the nurse to assess the client’s wishes regarding organ donation so that any necessary arrangements to preserve organs can be made prior to the client’s death.)