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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Techniques for performing neck ROM exercises might be relevant but are secondary to the immediate postoperative care following a cervical discectomy.

Choice B rationale

Restoring nerve function is a goal but not directly linked to discharge education strategies after cervical discectomy.

Choice C rationale

Home assessment of ABGs is not relevant to discharge education for a cervical discectomy, as it pertains more to respiratory status monitoring.

Choice D rationale

Care of the cervical collar is essential post-discectomy as it provides stability, reduces strain on the cervical spine, and supports the healing process, making it a critical part of discharge education.

A. Dysfunction of the spinal accessory nerve. B. Dysfunction of the acoustic nerve. C. Dysfunction of the facial nerve. D. Dysfunction of the vagus nerve. E. Dysfunction of the vagus nerve.

Correct Answer is D

Explanation

Choice A rationale

The spinal accessory nerve (cranial nerve XI) controls the sternocleidomastoid and trapezius muscles, which are responsible for movements of the head and shoulders. Dysfunction in this nerve would not affect the gag reflex.

Choice B rationale

The acoustic nerve (cranial nerve VIII) is responsible for hearing and balance. Dysfunction in this nerve would lead to hearing loss and balance issues, not an absent gag reflex.

Choice C rationale

The facial nerve (cranial nerve VII) controls muscles of facial expression and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. Dysfunction here results in facial paralysis or weakness but not in the absence of a gag reflex.

Choice D rationale

The vagus nerve (cranial nerve X) innervates muscles of the pharynx and larynx, which are involved in swallowing and the gag reflex. Dysfunction in the vagus nerve would result in an absent gag reflex, which is why the nurse determines this as the issue.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching?

Correct Answer is D

Explanation

A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the client has?

Correct Answer is D

Explanation

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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?