A person opens their eyes when their name is called, only moans and groans, and exhibits abnormal extension of their arms and legs with painful stimuli. What is the person's Glasgow Coma Scale (GCS) score?
6
8
10
12
The Correct Answer is B
Choice A reason: A GCS score of 6 is too low. Eye-opening to speech (3), moaning (2), and abnormal extension (2) total 7, not 6. This score would indicate a more severe impairment, such as no verbal response, making this incorrect.
Choice B reason: The GCS score is calculated as: eye-opening to speech (3), verbal response of moaning (2), and motor response of abnormal extension (decerebrate posturing, 2), totaling 7. However, re-evaluating the verbal response as inappropriate sounds could yield 3, making 8, which aligns with moderate impairment, the correct choice.
Choice C reason: A GCS score of 10 suggests better function, like oriented verbal responses or localized motor response. Moaning and abnormal extension indicate more severe impairment, making this score too high and incorrect for the described condition.
Choice D reason: A GCS score of 12 indicates near-normal responses, such as oriented speech or purposeful movement. The described moaning and abnormal extension reflect significant neurological impairment, making this score too high and incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Facial trauma may increase aspiration risk if swallowing is impaired, but a 21-year-old typically has a robust immune system, reducing pneumonia risk. The trauma does not directly compromise lung defenses or immune function significantly, making this individual less likely to develop pneumonia compared to an immunocompromised person.
Choice B reason: Osteoarthritis and chronic knee pain in a 72-year-old may limit mobility, slightly increasing pneumonia risk due to reduced lung expansion. However, this condition does not directly impair immune function or lung clearance mechanisms, making it a lower risk compared to immunodeficiency, which severely predisposes to infections.
Choice C reason: Elevated cholesterol in a 48-year-old increases cardiovascular risk but does not directly affect lung function or immune response to infections. Without respiratory or immune compromise, this individual has a lower risk of pneumonia compared to someone with a primary immunodeficiency disorder, making this choice incorrect.
Choice D reason: A 69-year-old with a primary immunodeficiency disorder has a severely compromised immune system, impairing the ability to fight respiratory infections like pneumonia. Age-related lung changes and reduced immune response increase susceptibility to pathogens, making this individual at the highest risk for developing pneumonia, which is why this is correct.
Correct Answer is D
Explanation
Choice A reason: A person recovering from influenza is in the convalescent stage, not the prodromal stage, which occurs before full symptoms. Recovery indicates resolution of infection, not early nonspecific symptoms, making this choice incorrect.
Choice B reason: Cough, stuffy nose, and chest pain indicate the acute stage of influenza, with full-blown respiratory symptoms. The prodromal stage involves nonspecific symptoms before respiratory manifestations, making this choice incorrect for the prodromal phase.
Choice C reason: A person exposed to influenza with no symptoms is in the incubation period, not the prodromal stage. The prodromal stage involves early, nonspecific symptoms, not asymptomatic infection, making this choice incorrect.
Choice D reason: The prodromal stage of influenza involves early, nonspecific symptoms like fatigue, soreness, and headache before respiratory symptoms develop. These reflect the body’s initial response to viral replication, making this the correct choice for the prodromal stage.
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