A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open their eyes, displays decerebrate posturing, and makes incomprehensible sounds. The nurse should assign the client which of the following Glasgow Coma Scale scores?

Answer and Explanation

The Correct Answer is D

A) 10: A score of 10 on the Glasgow Coma Scale (GCS) indicates a moderate level of impairment in consciousness. This score typically includes a range of responses in eye opening, verbal, and motor responses. Given the client's specific symptoms, this score does not accurately reflect their condition.

B) 13: A GCS score of 13 indicates mild impairment. This score usually requires the ability to open eyes spontaneously, follow commands, and exhibit appropriate verbal responses. Since the client is not opening their eyes and only making incomprehensible sounds, this score is not applicable.

C) 2: A score of 2 on the GCS would imply a severely compromised response, but it would be misleading since the client exhibits decerebrate posturing, which is a significant motor response indicating a level of neurological function. Thus, this score does not adequately represent the client's status.

D) 5: This is the correct score. The GCS includes a score of 1 for no eye opening, 2 for incomprehensible sounds, and 2 for decerebrate posturing. Adding these together (1 for eye opening + 2 for verbal + 2 for motor) results in a total of 5. This score reflects the severe impairment of consciousness and indicates the need for urgent medical evaluation and intervention.

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Correct Answer is A

Explanation

A) "I can assist you with making a list of foods you like for the dietitian.": This statement encourages the client to take an active role in their dietary management by involving them in the process of planning their meals. It fosters collaboration and empowers the client to express their preferences, making it more likely they will adhere to the dietary recommendations.

B) "I understand that the dietary choices can seem overwhelming.": While this statement acknowledges the client's feelings, it does not actively promote their involvement in the care plan. It reflects empathy but lacks the encouragement needed for the client to engage in managing their diabetes.
C) "Managing your diabetes will require you to make accommodations.": This statement emphasizes the need for change but may come across as directive and could potentially discourage the client. It doesn't foster a sense of partnership in the decision-making process.

D) "The dietitian will provide you with the best food choices to manage your diabetes.": Although this statement highlights the dietitian's expertise, it places the responsibility solely on the dietitian and does not encourage the client to participate in their own dietary decisions. Engaging the client in the conversation is key to enhancing their motivation and compliance.

A. "It is normal to feel this way after a morning run." B. "It becomes easier when exercise is a routine." C. "Were you careful to not have carbohydrates after the run?" D. "Did you decrease your insulin intake before you exercised?"

Correct Answer is D

Explanation

A) "It is normal to feel this way after a morning run.": While some fatigue can be expected after exercise, the client's symptoms of diaphoresis, palpitations, and exhaustion suggest that there may be an underlying issue related to their diabetes management, such as hypoglycemia. This response downplays the seriousness of their symptoms.

B) "It becomes easier when exercise is a routine.": While it is true that regular exercise can improve fitness and make physical activity feel easier over time, this response does not address the immediate concern of the client's current symptoms, which could indicate hypoglycemia.

C) "Were you careful to not have carbohydrates after the run?": This response suggests a misunderstanding of the client's needs. After exercise, especially for someone with type 1 diabetes, it is important to ensure adequate carbohydrate intake to prevent hypoglycemia. The client may need carbohydrates rather than avoiding them.

D) "Did you decrease your insulin intake before you exercised?": This is the most appropriate response. Clients with type 1 diabetes need to manage their insulin levels carefully, especially around exercise. If the client did not adjust their insulin dose or carbohydrate intake appropriately, they could be at risk for hypoglycemia, which explains their symptoms. This question encourages the client to reflect on their diabetes management in relation to their exercise.

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A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open their eyes, displays decerebrate posturing, and makes incomprehensible sounds. The nurse should assign the client which of the following Glasgow Coma Scale scores?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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