A patient with a head injury opens his eyes to verbal stimulation, shouts out when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because the patient's Glasgow Coma Scale score is 9. The Glasgow Coma Scale is a tool that assesses the level of consciousness of a patient with a head injury by measuring three parameters: eye opening, verbal response, and motor response. The patient's eye opening score is 3 (opens eyes to verbal command), verbal response score is 4 (confused speech), and motor response score is 2 (withdraws from pain). The total score is the sum of these three scores, which is 9.

Choice B Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 11. To get a score of 11, the patient would need to have a higher motor response score, such as 4 (withdraws to touch) or 5 (localizes to pain).

Choice C Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 15. To get a score of 15, the patient would need to have the highest scores for all three parameters, such as 4 (opens eyes spontaneously), 5 (oriented speech), and 6 (obeys commands).

Choice D Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 13. To get a score of 13, the patient would need to have a higher verbal response score, such as 5 (oriented speech).

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Correct Answer is C

Explanation

Choice A reason: This is incorrect because acute hemorrhagic stroke is not consistent with these observations. Acute hemorrhagic stroke is a sudden bleeding in the brain that can cause severe neurological deficits, such as paralysis, aphasia, or coma. It does not cause tremors, slowness, or mask-like facial expressions.

Choice B reason: This is incorrect because Alzheimer's disease is not consistent with these observations. Alzheimer's disease is a progressive degeneration of the brain that causes cognitive impairment, memory loss, and behavioral changes. It does not cause tremors, slowness, or mask-like facial expressions.

Choice C reason: This is the correct answer because Parkinson's disease is consistent with these observations. Parkinson's disease is a chronic disorder of the brain that affects movement and coordination. It causes tremors, slowness, rigidity, and postural instability, as well as mask-like facial expressions due to reduced facial muscle activity.

Choice D reason: This is incorrect because traumatic brain injury is not consistent with these observations. Traumatic brain injury is damage to the brain caused by external force, such as a blow, fall, or penetration. It can cause various neurological symptoms depending on the location and severity of the injury, but it does not typically cause tremors, slowness, or mask-like facial expressions.

A. Hemorrhage B. Spinal shock C. Apoptosis D. Neurogenic shock

Correct Answer is B

Explanation

Choice A Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue.

Choice B Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord.

Choice C Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time.

Choice D Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.

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A patient with a head injury opens his eyes to verbal stimulation, shouts out when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes the client as he walks into the clinic. She notices a slight tremor of the hands, slowness of movements, and a mask-like facial expression, with postural instability. Which of the following in the client's history are consistent with these observations?

Correct Answer is C

Explanation

A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?

Correct Answer is B

Explanation

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