The nurse is caring for a client with a neurological deficit. In assessing the client, the nurse will utilize the standard Glasgow Coma Scale. What will the nurse be assessing on this patient? Select all that apply.
Thought process.
Verbal response.
Motor response.
Eye response.
Cognitive ability.
Correct Answer : B,C,D
The Glasgow Coma Scale (GCS) is a tool used to assess a patient's level of consciousness following a traumatic brain injury. It is based on three categories: eye-opening, verbal response, and motor response. The tool scores a patient from 3 to 15, with 15 being the best possible score. A score of 8 or less indicates a severe brain injury. The tool does not assess thought process or cognitive ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Tinnitus and sensorineural hearing loss. Salicylates, loop diuretics, quinidine, quinine, or aminoglycosides can cause ototoxicity, which includes tinnitus (ringing in the ears) and sensorineural hearing loss. Therefore, the nurse should monitor the client for auditory changes and report them to the healthcare provider immediately.
Option A, impaired facial movement, is incorrect because it is a sign of facial nerve paralysis, which can occur due to Bell's palsy, stroke, or brain injury.
Option B, signs of hypotension, is incorrect because it can be caused by antihypertensive drugs or dehydration, not the drugs listed.
Option D, reduced urinary output, is incorrect because it can be a sign of acute kidney injury or dehydration, not the drugs listed.
Correct Answer is A
Explanation
Exposing the affected area to air. Exposing the affected area to air is appropriate because it allows the skin to breathe and reduces the risk of skin breakdown. The client should be instructed to change the pad frequently and wash the perineal area with mild soap and water.
Option B, avoiding the application of moisture sealant, may increase the risk of skin breakdown.
Option C, avoiding using an electric room deodorizer, is not related to the situation.
Option D, using scented sprays or perfumes, may cause skin irritation.
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