A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client’s Glasgow coma scale rating is 15.
Which of the following findings should the nurse expect?
The client withdraws from pain.
The client is unable to obey commands.
The client opens eyes to sound.
The client is oriented times three.
The Correct Answer is D
This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.
Choice A is wrong because the client withdraws from pain.
This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.
Choice B is wrong because the client is unable to obey commands.
This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.
Choice C is wrong because the client opens eyes to sound.
This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.
The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.
It consists of three tests: eye opening, verbal response, and motor response.
Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should instruct the assistive personnel to report any changes in the position of the weight or the traction system to the nurse immediately.
Choice B is wrong because checking the client’s pedal pulse on the right leg requires assessment skills and clinical judgment that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to monitor the client’s circulation and nerve function in the affected limb.
Choice C is wrong because asking the client to describe her pain requires communication and assessment skills that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to evaluate the client’s pain level and response to analgesics.
Choice D is wrong because reminding the client to use the incentive spirometer requires teaching and evaluation skills that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to promote effective gas exchange and prevent respiratory complications in the client who is immobile.
Buck’s traction is a type of skin traction that is applied by strapping the client’s affected lower limb and attaching weights. The purpose of traction is to restore and maintain straight alignment and length of bones following fractures, to limit movement and reduce pain, spasms and swelling. Normal ranges for skin traction are 2.3 to 4.5 kg for adults and 0.9 to 2.3 kg for children.
Correct Answer is D
Explanation
This prescription is complete because it includes the medication name, dose, route, and frequency. A complete prescription should also include the client’s name, date, time, signature of the prescriber, and any special instructions.
Choice A is wrong because it does not specify the dose of cimetidine.
PO twice daily is not enough information to administer the medication safely. Choice B is wrong because it does not specify the frequency of tetracycline.
200 mg PO is not enough information to administer the medication safely. Choice C is wrong because it does not specify the route of epoetin alfa.
150 units/kg three times weekly is not enough information to administer the medication safely.
Normal ranges for digoxin are 0.5 to 2 ng/mL for heart failure and 0.8 to 2 ng/mL for atrial fibrillation.
Normal ranges for cimetidine are 50 to 150 ng/mL. Normal ranges for tetracycline are 1 to 10 mcg/mL.
Normal ranges for epoetin alfa are not applicable as it is a synthetic hormone that stimulates red blood cell production.
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