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 ["100"]

Explanation

Step by step calculation:

Determinethevolumetobeinfused:50mL

Determinethetimeoverwhichtheinfusionshouldbeadministered:30minutes

CalculatetheinfusionrateinmLperhour:

Infusionrate(mL/hr)=Totalvolume(mL)/Infusiontime(hours)

Converttheinfusiontimetohours:

30minutes=0.5hours

Applytheformula:

Infusionrate(mL/hr)=50mL/0.5hours=100mL/hr

A. Temperature of 37.9° C (100.2° F) B. Urine output 150 mL over 4 hr C. Bruising around the incisional site D. Pallor in the affected extremity

Correct Answer is D

Explanation

A) Temperature of 37.9° C (100.2° F): A slight elevation in temperature can be common after surgery and may not indicate a serious issue. It should be monitored, but it is not immediately concerning.

B) Urine output 150 mL over 4 hr: While urine output is an important indicator of kidney function and overall perfusion, this output may still be acceptable depending on the client's overall fluid status and other factors. It does not necessarily require immediate reporting unless there are other concerning symptoms.

C) Bruising around the incisional site: Some bruising can be expected after surgery, particularly with arterial procedures. It should be monitored, but unless there are signs of excessive bleeding or hematoma formation, it is not typically an urgent concern.

D) Pallor in the affected extremity: This finding is critical and should be reported immediately. Pallor could indicate compromised blood flow to the extremity, which could be a sign of complications such as graft occlusion or inadequate perfusion. Prompt intervention may be necessary to prevent serious complications or tissue loss.

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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 ["100"]

Explanation

A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is D

Explanation

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