A nurse is performing a Glasgow Coma Scale assessment. She will evaluate all of the following except

eye opening.

sensory response.

verbal response.

motor response.

Answer and Explanation

The Correct Answer is B

A. Eye opening is a core component of the Glasgow Coma Scale (GCS) and is assessed to determine the level of consciousness. Scores range from 1 (no eye opening) to 4 (spontaneous eye opening).

B. Sensory response is not directly assessed in the Glasgow Coma Scale. While neurological exams may include sensory testing (e.g., pain, touch, temperature), the GCS specifically evaluates eye opening, verbal response, and motor response.

C. Verbal response is a main component of the GCS, assessing the patient’s ability to speak coherently and appropriately. Scores range from 1 (no verbal response) to 5 (oriented conversation).

D. Motor response is a key part of the GCS, evaluating purposeful or reflexive movements. Scores range from 1 (no motor response) to 6 (obeys commands).

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Correct Answer is C

Explanation

A. While skin care is part of overall nursing care, the integumentary system is not the primary concern in Guillain-Barré syndrome (GBS). Pressure injuries may occur if mobility is limited, but deterioration in this system is not life-threatening.

B. Bladder dysfunction can occur in GBS, but it is not usually the most critical system at risk for rapid deterioration. Nursing interventions may include monitoring urinary output and preventing urinary retention, but it is secondary to respiratory monitoring.

C. GBS often causes progressive muscle weakness, including the diaphragm and intercostal muscles, leading to respiratory compromise. The nurse must carefully monitor respiratory status, including respiratory rate, effort, oxygen saturation, and signs of hypoventilation, as respiratory failure is a major complication and can be life-threatening.

D. Cardiovascular complications such as autonomic dysfunction (e.g., fluctuations in blood pressure or heart rate) can occur in GBS, but the immediate priority is respiratory monitoring because respiratory failure can occur rapidly and requires urgent intervention.

A. Plan to add additional weights as the fracture heals, usually once per day. B. Ensure traction weights are hanging freely, not touching the bed or floor. C. Remove traction weights once per shift for 30 minutes and then replace them. D. Have the unlicensed assistive personnel remove the weights daily and encourage the child to move around in bed.

Correct Answer is B

Explanation

A. Traction weights are prescribed by the healthcare provider and should not be adjusted by the nurse unless specifically ordered. Changing weights without an order can compromise fracture alignment or cause injury.

B. Proper traction requires constant, uninterrupted force to maintain fracture alignment. Weights must hang freely to provide the correct pull; if they touch the bed or floor, traction effectiveness is lost, potentially delaying healing or causing malalignment. This is a fundamental aspect of safe traction care.

C. Traction weights are continuous unless ordered to be temporarily released for specific procedures. Routine removal disrupts the therapeutic force and can interfere with fracture healing or cause complications.

D. Traction management is a licensed nursing responsibility, especially when it involves weights and maintaining proper alignment. UAPs can assist with positioning or hygiene, but they should not remove weights, and ambulation is generally restricted depending on fracture type and traction method.

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A nurse is performing a Glasgow Coma Scale assessment. She will evaluate all of the following except

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for the child with Guillain-Barré syndrome the nurse will provide much supportive care while watching carefully for signs of deterioration in which body system?

Correct Answer is C

Explanation

The nurse is caring for a child in traction with a fractured femur. Which action will the nurse complete while caring for this client?

Correct Answer is B

Explanation

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