The Glasgow Coma Scale is being used to monitor a client who experienced a traumatic brain injury. What primary assessment should the practical nurse (PN) evaluate?

Mental status

Cranial nerve status:

Level of consciousness.

Ability to communicate.

Answer and Explanation

The Correct Answer is C

A. Mental status: Mental status assessment is broad and includes multiple components such as mood, orientation, and cognition. While important, it is not the primary focus of the Glasgow Coma Scale (GCS).

B. Cranial nerve status: Cranial nerve assessment evaluates specific neurological function, but the GCS specifically measures overall neurological responsiveness rather than individual cranial nerves.

C. Level of consciousness: The Glasgow Coma Scale is designed to assess a client’s level of consciousness through eye, verbal, and motor responses. Monitoring changes in consciousness provides critical information about brain function and potential deterioration.

D. Ability to communicate: Communication is one component of the GCS (verbal response), but the scale also incorporates eye and motor responses. Level of consciousness encompasses overall neurological status, making it the primary assessment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Gently pull the upper aspect of the ear lobe upwards and backwards: For children older than 3 years, this straightens the ear canal to allow proper delivery of the medication into the external auditory canal.

B. Gently pull the lower aspect of the ear lobe downwards and forward: This technique is appropriate for infants and children younger than 3 years, as their ear canal angles differently.

C. Hold the upper aspect of the ear lobe downwards and against the skull: This position would obstruct the ear canal rather than open it, preventing proper medication flow.

D. Instill one drop q5 minutes with the child in a Trendelenburg position: Trendelenburg positioning is unnecessary and unsafe for ear drop administration; the child should simply remain with the affected ear upward for several minutes.

A. Quinapril. B. Spironolactone C. Losartan. D. Clonidine.

Correct Answer is A

Explanation

A. Quinapril: Quinapril is an angiotensin-converting enzyme (ACE) inhibitor. A persistent dry cough is a well-known side effect due to accumulation of bradykinin in the respiratory tract. Clients should be informed that the cough may resolve after discontinuation or switching to another antihypertensive class.

B. Spironolactone: Spironolactone is a potassium-sparing diuretic and does not commonly cause a dry cough. Its primary side effects include hyperkalemia, gynecomastia, and menstrual irregularities rather than respiratory symptoms.

C. Losartan: Losartan is an angiotensin II receptor blocker (ARB) and is less likely to cause a cough. It is often used as an alternative for clients who develop a cough with ACE inhibitors.

D. Clonidine: Clonidine is an alpha-2 adrenergic agonist used for hypertension. Common side effects include sedation, dry mouth, and hypotension, but it does not typically produce a persistent dry cough.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The Glasgow Coma Scale is being used to monitor a client who experienced a traumatic brain injury. What primary assessment should the practical nurse (PN) evaluate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribed ear drops for a 5-year-old girl with otitis externa. Which technique should the practical nurse (PN) advise the mother to use when administering the ear drops?

Correct Answer is A

Explanation

A client with hypertension complains of a persistent dry cough. The practical nurse (PN) should tell the client that this is a common side effect of which daily medication?

Correct Answer is A

Explanation

The practical nurse (PN) is caring for a client receiving a prescription for paroxetine who suddenly exhibits restlessness, tachycardia, fever, and elevated blood pressure. Which action should the PN implement first?

The practical nurse (PN) is caring for a client receiving chemotherapy who has thrombocytopenia. Which intervention is most important to include in the nursing plan of care?

The practical nurse (PN) is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body?

The practical nurse (PN) is assigned to provide care for a client with rheumatoid arthritis who is preparing for discharge. In planning the client's care, the PN should identify which client goal as the most important?

During a home visit, the home health practical nurse (PN) observes an older client attempting to ambulate to the bathroom and notes that the client is unsteady and holds on to furniture while refusing any assistance. Which action should the PN implement?

A client receives a prescription for a medication to be administered three times a day before meals, The food tray arrives on the unit at 0900, 1200, and 1700. At what times should the practical nurse administer the medication? Select all that apply

The practical nurse (PN) is participating in a health promotion program for a group of adults at a health fair about life style choices. Which information is most important for the PN to emphasize?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to with each dose? (Enter numerical value only.)