A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?

Monro-Kellie hypothesis

Glasgow Coma Scale

Cranial nerve function

Mental status examination

Answer and Explanation

The Correct Answer is B

A. Monro-Kellie hypothesis: The Monro-Kellie hypothesis explains the relationship between the volumes of brain tissue, blood, and cerebrospinal fluid in the cranium, but it is not a diagnostic tool for assessing LOC.

B. Glasgow Coma Scale: The Glasgow Coma Scale (GCS) is a standardized tool used to assess a client's level of consciousness, particularly in cases of head injury. It evaluates eye opening, verbal response, and motor response.

C. Cranial nerve function: Cranial nerve assessment is important in evaluating neurological function, but it is not a comprehensive tool for gauging LOC.

D. Mental status examination: A mental status examination assesses cognitive functions, but the Glasgow Coma Scale is more appropriate for evaluating LOC in the context of head trauma.

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Correct Answer is C

Explanation

A. Leave the client alone during a new experience. Leaving an anxious client alone during a new experience may increase their anxiety and hinder the development of trust. Clients need support and reassurance during unfamiliar situations.

B. Give support in nonverbal ways. Nonverbal support, such as a calm presence or gentle touch, can be comforting and help build trust without overwhelming the client with too much verbal communication.

C. Be available and attentive to the client's requirements. Being available and attentive shows the client that the nurse is reliable and responsive to their needs, which helps build trust in the therapeutic relationship.

D. Give detailed explanations and do not repeat them frequently. While providing detailed explanations is important, failing to repeat them as needed could leave the client feeling unsupported or confused, especially if they need reassurance.

A. The client can obtain and maintain employment. B. The client is free from aggressive behaviors. C. The client utilizes relaxation techniques. D. The client maintains healthy relationships with others.

Correct Answer is B

Explanation

A. The client can obtain and maintain employment. While obtaining and maintaining employment can be a positive outcome, it does not specifically address the control of aggressive behaviors which are the focus here.

B. The client is free from aggressive behaviors. Being free from aggressive behaviors directly reflects successful treatment of aggressive symptoms in schizophrenia. This outcome specifically addresses the primary concern.

C. The client utilizes relaxation techniques. Utilizing relaxation techniques can be part of managing symptoms but does not directly measure the control of aggressive behaviours.

D. The client maintains healthy relationships with others. Maintaining healthy relationships is a positive outcome, but it is a broader goal and does not directly indicate control of aggressive behaviours.

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A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?

Nursing Test Bank

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