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Unit 2 Exam - Med Surg Evolve Review questions
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The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls (select all that apply.)?
Sensory deficit, Motor function deficit, Central nervous system changes
Normal changes of aging in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. These changes all contribute to an increased risk of falls for the older adult. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not increase the risk for falls.
The nurse is admitting a patient with a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient?
Higher cognitive function abnormalities
Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.
When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment?
Ataxia
Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.
The nurse is completing a health assessment for a newly admitted patient. Which assessment should the nurse perform to determine the cognitive function of the patient?
Ask the patient a question such as, "Who were the last three presidents?"
Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, "Who were the last three presidents?" General appearance and behavior are additional components and include level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination, and may include testing rapid alternating movements of the upper and lower extremities.
In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves?
A 50-yr-old woman with lethargy from a drug overdose
The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, brainstem lesion, or disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.
The nurse is performing a neurologic assessment for a patient. When assessing the accessory nerve, what action should the nurse take?
Ask the patient to shrug the shoulders against resistance.
The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.
The nurse is preparing the patient for an electromyogram (EMG). What should the nurse include in teaching the patient before the test?
The pain that occurs is from the insertion of the needles.
With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is not tilted on a table during a myelogram. The electroencephalogram is noninvasive without a danger of electric shock. The magnetoencephalogram is done with a passive sensor that does not make contact with the patient.
How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury?
Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance.
The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.
A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery?
Altered sense of smell
Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.
A patient's sudden onset of hemiplegia has necessitated a CT scan of her head. Which action should be the nurse's priority before this diagnostic study?
Assess the patient for allergies to shellfish, iodine, or dyes.
Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients.
The nurse is caring for a group of healthy older adults at a community day center. Which neurologic finding associated with aging would the nurse expect to note in older adults?
Orthostatic hypotension
Older adults are more likely to experience orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in older adults include atrophy of taste buds with decreased sense of taste, below-average reflex score (and diminished deep tendon reflexes), and slowed reaction times.
A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomogram (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study?
Regular insulin 6 units (SQ)
Patients with type 1 diabetes mellitus must have insulin administered the day of the PET if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET of the brain because the patient may need to perform mental activities, and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET of the brain and should not receive oral medications (alprazolam and ciprofloxacin).
The nurse is caring for a patient after a lumbar puncture. Which is a priority action by the nurse?
Assess for drainage or bleeding from the puncture site.
After a lumbar puncture, the nurse should monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.
The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation does the nurse assess in this patient?
Impaired muscle movement
Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in level of consciousness, impaired reflexes, or decreased sensation.
When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How should the nurse mostaccurately document this finding?
Pronator drift
Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.
A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department?
Maintenance of the patient's airway
Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program?
Hypertension
Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.
The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient?
Safety measures
A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.
The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene?
Assessing cranial nerves III, IV, and VI before attempting feeding
The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. Cranial nerves III, IV, and VI are responsible for ocular movements. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.
A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity?
Alternate the patient's positioning between supine and side-lying.
A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.
A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first?
Arrange for several servings per day of cooked fruits and vegetables.
Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.
The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping?
Rehabilitation potential of the patient
Although a patient's neurologic deficit might initially be severe, the ability of the patient to recover is most likely to positively impact the family's coping. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.
Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)?
Slow and possibly fearful performance of tasks
Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.
When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN?
Administer scheduled anticoagulant medications.
Assessment and screening are considered part of the registered nurse scope of practice. The LPN/LVN can administer PO or subcutaneous anticoagulant medications. Anticoagulant medications are considered high risk and should be double checked with another LPN/LVN or RN. The UAP can place equipment needed for seizure precautions in the room.
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply.)?
Ticlopidine
Clopidogrel
Dipyridamole
Enteric-coated aspirin
Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel, dipyridamole, ticlopidine, combined dipyridamole and aspirin, and anticoagulant drugs such as oral warfarin. Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs or strokes.
The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information?
"Call 911 immediately if a person develops slurred speech or difficulty speaking."
Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.
The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate?
Subarachnoid hemorrhage
Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.
The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke?
Impaired speech
Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.
Which intervention is most appropriate when communicating with a patient with aphasia after a stroke?
Use simple, short sentences accompanied by visual cues to enhance comprehension.
When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke?
A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco
Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor, and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.
The patient's magnetic resonance imaging revealed the presence of a brain tumor. The nurse anticipates which treatment modality?
Surgery
Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.
What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)?
Monitor fluid and electrolyte status carefully.
Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.
The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)?
Eye opening
Best verbal response
Best motor response
The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
Which conditions can lead to the development of a brain abscess h (select all that apply.)?
Endocarditis
Ear infection
Tooth abscess
Skull fracture
Sinus infection
Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess.
A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement?
Serum osmolality of 290 mOsm/kg
Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.
A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started?
Malnutrition promotes continued cerebral edema.
A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Excess intravenous fluid administration will also increase cerebral edema.
The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for (select all that apply.)?
Seizures
Vision loss
Cerebral edema
Pituitary dysfunction
Focal neurologic deficits
Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.
A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results?
Impaired blood flow to the brain
Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80 mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.
The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present?
Resistance to flexion of the neck
Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.
A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate?
Apply a loose gauze pad under the patient's nose.
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.
A patient experienced head trauma in a car crash. There are many steps in the pathophysiology of the progression from injury to severe increased intracranial pressure (ICP) and death. In which order do the listed events occur? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) __ a. Decreased cerebral blood flowb. Increased ICP with brainstem compressionc. Increased ICP from increased blood volumed. Compression of ventricles and blood vesselse. Tissue edema from initial insult
E, F, D, A, B, C
After initial insult to the brain, there is tissue edema, which causes an initial increase in ICP, then compression of ventricles and blood vessels, which decreases cerebral blood flow, thus decreasing O2 and causing death of brain cells. Edema occurs around this necrotic tissue, and ICP is increased with compression of the brainstem and respiratory center leading to accumulation of CO2. ICP is further increased from increased blood volume that leads to death.
The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)?
Bradycardia
Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.
A 68-yr-old man with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first?
Ceftriaxone (Rocephin)
Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).
The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication?
Absolute neutrophil count and platelet count
Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be greater than 1500/ìL and platelet count greater than 100,000/ìL.
The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority?
Use strict aseptic technique with dressing changes.
The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.
Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated intracranial pressure (ICP), causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like which posture represented below?
Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury.
Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated intracranial pressure (ICP), causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like which posture represented below?
Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury.
The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action?
Assess the patient's level of consciousness.
The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.
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