Mrs Bago, 80 years old, is a resident of the rest home where yo
u are on student placement. Whilst playing cards in the day roo
m with a fellow resident she became unresponsive without war
ning for about 30 seconds. Five minuteshave passed and she h
as now regained consciousness and is lying on her bed, after b
eing taken there by her career.
Answer:The Activities Coordinator reported that she had some
slurring of speech immediately after regaining consciousness.
Which of the following would be most appropriate for you as the
student nurse to do next?
A. Leave Mrs Bago to go and talk to the other residents about
what happened.
B. Perform a Glasgow Coma Score (GCS).
C. Refer the patient for immediate follow-up.
D. Ask if the patient has ever had a seizure
Answer:B. Perform a glasgow coma scale
When performing a physical examination of Winnie which of the
following would be most appropriate?
A. Allow Winnie to remain dressed.
B. Omit intrusive parts of the exam.
,C. Dim the room light.
D. Try to minimise position changes for her.
Answer:D. Try to minimise position changes for her
Which test would be most appropriate to perform when assessi
ng Winnies eye muscle strength and cranial nerve function?
A. Visual fields test.
B. Cover test.
C. Corneal light reflex test.
D. Extra ocular movement test.
Answer:D. Extra ocular movement test
Which of the following nursing assessments will give you object
ive data relating to the functioning of Winnies cerebellum?
A. Vital signs.
B. Coordination.
C. Glasgow Coma Score
D. Cardiac function.
Answer:B. Coordination
, The registered nurse is having difficulty eliciting a patellar reflex.
Which of the following would be most appropriate for the nurse
to have Winnie do?
A. Lock the fingers together and pull against each other.
B. Stretch the arms over head.
C. Squeeze a thigh with the opposite hand.
D. Clench the jaw tightly.
Answer:A. Lock the fingers together and pull against each other
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Winnies patellar reflex is normal. Which of the following is the c
orrect number to document this?
A. 2+
B. 3+
C. 4+
D. 5+
Answer:A. 2+
Which of the following would be the most likely sign of a frontal
lobe contusion?
A. Inability to hear high-pitched sounds
B. Difficulty speaking
C. Blurred vision
D. Loss of tactile sensation