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 C

Explanation

A. While this is a good safety measure for any client, it doesn't address the specific issue of homonymous hemianopsia.
B. This can be helpful for clients with motor difficulties but does not address the visual impairment.
C. Since the client has a right-sided stroke and homonymous hemianopsia, they will likely miss food on the left side of their tray. Reminding them to scan that area can help prevent them from missing food.
D. While this might seem logical, it doesn't address the underlying issue of the client's visual impairment.

A. The client who has chronic kidney disease B. The client experiencing an asthma attack C. The client who has Guillain-Barré syndrome D. The client who has a severe burn injury

Correct Answer is C

Explanation

A. This client is at risk for other complications such as electrolyte imbalances or heart failure, but not specifically neurogenic shock.
B. This client is experiencing respiratory distress, which is a different type of shock (anaphylactic or septic shock might be considered, but not neurogenic).

C. Guillain-Barré syndrome is an autoimmune disorder that affects the nervous system, often leading to paralysis. It can cause a rapid loss of muscle function, which can result in neurogenic shock due to loss of sympathetic nervous system tone.
D. This client is at risk for hypovolemic shock due to fluid loss, not neurogenic shock.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAI The graduate nurse demonstrates correct understanding when he states which of the following:

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. Available is meperidine injection 75 mg/mL. How m mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Exhibits A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching? Client Statements

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

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

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?

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?