A nurse assesses a client with a brain injury. The client opens his eyes when the nurse calls his name, does not understand questions, and brings his arm up in response to a trapezius squeeze by the nurse. How would the nurse document this client's assessment using the Glasgow Coma Scale shown below

Answer and Explanation

The Correct Answer is D

The client opens his eyes in response to voice, which scores 3 on the eye-opening part of the GCS.

Since the client does not understand questions, this would likely score 1 for verbal response, indicating incomprehensible sounds.

The motor response of bringing an arm up to a trapezius squeeze is localizing pain, which would score 5.

Therefore, the nurse would document the client's GCS score as E3V1M5, which totals to 9 out of a possible 15 points.

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Correct Answer is D

Explanation

A. Widening pulse pressure is typically associated with increased cardiac output, which is opposite to what happens in hypovolemic shock.
B. Pulse oximetry 96% is a normal oxygen saturation level and does not indicate shock.
C. Increased deep tendon reflexes is not a typical finding in hypovolemic shock.
D. Increased heart rate is a classic compensatory mechanism in response to decreased blood volume. The body tries to maintain blood pressure by increasing heart rate.

A. Administer supplemental oxygen to the client. B. Restrain the client. C. Time the duration of the seizure. D. Place a tongue depressor in the client's mouth. E. Turn the client to the side

Correct Answer is ["A","C","E"]

Explanation

A. The client is experiencing apnea and has decreased oxygen saturation, indicating a need for supplemental oxygen.
B. Restraining a client during a seizure is dangerous and can cause injury.
C. This information is crucial for determining the type of seizure and guiding treatment.
D. Placing a tongue depressor in the client's mouth can cause trauma to the teeth and mouth and should never be done.
E. Turning the client to the side helps prevent aspiration of saliva or vomit, protecting the airway.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Correct Answer is D

Explanation

Exhibits A nurse is caring for a client who has a seizure disorder. (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

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A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?