HESI Comprehensive Exit Exam 1 (And Rationale)

D (Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness, as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. The other assessment data choices are late signs of altered cerebral function.) The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? a. Unequal pupils. b. Loss of central reflexes. c. Inability to open the eyes. d. Change in level of consciousness. D (A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated by tight-fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended because it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fiber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments, provide absorbancy and reduce moisture in the perineal area.) A nurse is planning to teach self-care measures to a f