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 B
Explanation
Sips of fluid may be increased if tolerated. After a barium enema, the client may be allowed to increase fluid intake to help eliminate the barium and prevent constipation.
Option A: The client will maintain a low-residue diet is not a correct answer as it is not necessary after a barium enema.
Option C: An enema will be used to clear the bowel is not a correct answer as the barium enema is itself a type of enema used to visualize the colon.
Option D: The stools may be white or clay-colored is not a correct answer as it is a potential side effect of barium use, not an instruction to the client.
Correct Answer is D
Explanation
A blood glucose reading of 48 is considered low and requires immediate intervention to raise the client's blood sugar. Intravenous dextrose solution is the fastest way to raise blood sugar levels in an unconscious client. Glucagon and cortisone can also be used to raise blood sugar levels, but they are not the first-line treatment for hypoglycemia.
Choice A, orange juice, is not appropriate for an unconscious client as they cannot swallow or drink.

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