Mrs Winnie Bago Flashcards
Mrs. Bago, 80 years old, is a resident of the rest home where you are a student nurse on placement. Whilst playing cards in the day room with a fellow resident she became unresponsive without warning for about 30 seconds. Five minutes have passed and she has now regained consciousness and is lying on her bed after being taken there by her carer. The activities coordinator reported that she had some slurring of speech immediately after regaining consciousness.
Which of the following would be the 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 of the patient has ever had a seizure.
B. Perform a Glasgow Coma Score (GCS).
When performing a physical examination of Winnie which of the following would be the most appropriate?
A. Allow Winnie to remain dressed.
B. Omit intrusive parts of the examination.
C. Dim the room light.
D. Try to minimize position changes for her.
D. Try to minimize position changes for her.
Which test would be most appropriate to perform when assessing Winnie’s eye muscle strength and cranial nerve function?
A. Visual fields test.
B. Cover test.
C. Corneal light reflex test.
D. Extra occular movement test.
D. Extra occular movement test.
Which of the following nursing assessments will give you objective data relating to the functioning of Winnie’s cerebellum?
A. Vital signs.
B. Coordination.
C. Glasgow Coma Score.
D. Cardiac function.
B. Coordination.
The RN is having difficulty eliciting a patellar reflex. Which of the following would be the 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.
A. Lock the fingers together and pull against each other.
Winnie’s patellar reflex is normal. Which of the following is the correct number to document this?
A. 2+
B. 3+
C. 4+
D. 5+
A. 2+
Which of the following would be the most likely sign of a frontal lobe contusion?
A. Inability to hear high pitched noises.
B. Difficulty speaking.
C. Blurred vision.
D. Loss of tactile sensation.
B. Difficulty speaking.
