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 B

Explanation

A. In DIC, there is actually a consumption of clotting factors rather than an increase. The widespread activation of the clotting cascade leads to the consumption of clotting factors and platelets as they are used up in forming numerous small blood clots throughout the body. This depletion results in a paradoxical bleeding tendency due to a shortage of clotting factors.
B. This is characteristic of DIC. The condition involves both excessive clotting (thrombosis) and bleeding. The formation of small clots throughout the microcirculation leads to organ damage and depletion of clotting factors and platelets, which in turn causes bleeding tendencies. This dual process of clot formation and bleeding is a hallmark of DIC.
C. In DIC, there is a decrease in platelet count, not an increase. The condition causes widespread clotting, which consumes platelets rapidly, leading to a low platelet count. Therefore, a progressive increase in platelet count would not be expected in DIC.
D. Sodium and fluid retention are not primary features of DIC. Instead, DIC typically presents with symptoms related to clotting and bleeding rather than fluid balance. Fluid retention would be more associated with other conditions like heart failure or renal disorders, not directly with DIC.

A. Spinal cord degeneration B. Decorticate posturing C. Atypical hyperreflexia D. Decerebrate posturing

Correct Answer is D

Explanation

A. Spinal cord degeneration is a general term for the deterioration of the spinal cord and doesn't specifically describe the patient's posture.
B. Decorticate posturing is characterized by the arms flexed and adducted, with the wrists and fingers flexed. The legs are extended and adducted, with the feet plantar flexed.
C. Atypical hyperreflexia refers to exaggerated reflexes, not a specific posture.

D. Decerebrate posturing is characterized by the arms extended and pronated, with the wrists and fingers flexed. The legs are stiffly extended with plantar flexion.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

Correct Answer is D

Explanation

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following actions should the nurse take?

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?

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?

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?