The Nurse Is Planning to Use the FOUR Tool to Assess

question 36

Multiple Choice

The nurse is planning to use the FOUR tool to assess a patient's neurological functioning.In which areas should the nurse collect data when using this tool? (Select all that apply.)

• A) Reflexes
• B) Eye response
• C) Verbal response
• D) Motor movement
• E) Breathing pattern

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Definitions:

Peripheral Extremity Circulation

Blood flow to the limbs of the body, crucial for delivering oxygen and nutrients and removing metabolic wastes.

Right-sided Heart Failure

Right-sided heart failure occurs when the right ventricle of the heart is unable to pump blood efficiently, often leading to fluid buildup in the body.

Peripheral Edema

Swelling caused by an accumulation of fluid in the tissues, typically occurring in the lower legs and ankles.

Basilar Crackles

Fine or coarse sounds heard in the lower part of the lungs with a stethoscope, usually indicating fluid in the airways or atypical airway popping open, often associated with conditions like pneumonia or heart failure.