The critical care nurse is giving end-of-shift report on a client.
The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
Stupor.
Somnolence.
Normal.
Deep coma.
The Correct Answer is D
Choice A rationale
Stupor refers to a state of near-unconsciousness or insensibility, where the patient can be briefly aroused by vigorous or repeated stimuli.
Choice B rationale
Somnolence refers to a state of strong desire for sleep or sleeping for unusually long periods (drowsiness), but it is not as severe as stupor or coma.
Choice C rationale
Normal consciousness means the patient is awake, alert, and responsive to their environment with no neurological deficits.
Choice D rationale
A score of 6 on the Glasgow Coma Scale indicates deep coma, where the patient has minimal to no response to stimuli, indicating severe brain injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Gently pressing the bones on the neck does not effectively test for neck rigidity, which is a common indicator of meningeal irritation or inflammation. This method may detect tenderness or bony abnormalities but not rigidity.
Choice B rationale
Moving the head toward both sides primarily assesses range of motion and flexibility. While reduced range of motion can be noted, this method doesn't specifically test for the resistance characteristic of neck rigidity.
Choice C rationale
Lightly tapping the lower portion of the neck to detect sensation tests for sensory nerve function but is not relevant to assessing muscle tone or rigidity, which is related to motor nerve and muscular response.
Choice D rationale
Moving the head and chin toward the chest is a proper technique to test for neck rigidity. This maneuver can elicit pain or resistance in cases of meningeal irritation, providing a reliable assessment for rigidity.
Correct Answer is B
Explanation
Choice A rationale
Hematoma formation is the initial stage of fracture healing, where a blood clot forms around the fracture site, creating a foundation for subsequent healing phases.
Choice B rationale
Remodeling is the final phase of bone healing, where compact bone replaces spongy bone, restoring the bone's structure and function.
Choice C rationale
Bony callus formation involves the development of new bone (callus) around the fracture site, which eventually transitions to compact bone during remodeling.
Choice D rationale
Fibrocartilaginous callus formation is an earlier stage of fracture healing, characterized by the formation of a soft callus made of collagen and cartilage that stabilizes the fracture.
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