The nurse is caring for a client with brain trauma who is in a coma. The client's Glascow Coma Scale is 6. Which response would the nurse expect the client to have?

Able to localize pain

Is verbally responsive, but confused

Moves arms as directed

Opens eye to deep pain only

Answer and Explanation

The Correct Answer is D

A. Able to localize pain: A score of 6 is too low for a client to localize pain, which would require higher motor function.

B. Is verbally responsive, but confused: Verbal responsiveness would require a higher score, as a GCS of 6 indicates severe impairment.

C. Moves arms as directed: Following commands is consistent with a higher GCS score.

D. Opens eyes to deep pain only: This response aligns with the minimal responsiveness expected for a GCS score of 6.

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Correct Answer is D

Explanation

A. Subdural hematoma: Subdural hematomas develop more slowly and typically present a higher risk for delayed deterioration, but not usually within the first 24 hours.

B. Diffuse axonal injury: While severe, diffuse axonal injury typically causes a prolonged coma rather than immediate fatality within 24 hours.

C. Intracranial hemorrhage: This is severe but often depends on the size and location of the bleed.

D. Epidural hematoma: Epidural hematomas are associated with arterial bleeding and rapid deterioration due to increased intracranial pressure, making them the most fatal within 24 hours.

A. It occurs immediately when buttons depressed. B. It requires a higher amount of joules than is used in defibrillation. C. It discharges during ventricular depolarization of the heart. D. It is programmed to occur in non-sync mode.

Correct Answer is C

Explanation

A. It occurs immediately when buttons depressed: The device synchronizes with the R wave and does not deliver the shock immediately.

B. It requires a higher amount of joules than is used in defibrillation: Cardioversion typically requires fewer joules compared to defibrillation.

C. It discharges during ventricular depolarization of the heart: Synchronized cardioversion times the electrical shock with the R wave (ventricular depolarization) to avoid delivering energy during the T wave, which could induce ventricular fibrillation.

D. It is programmed to occur in non-sync mode: Cardioversion must be synchronized; non-sync mode is used in defibrillation.

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The nurse is caring for a client with brain trauma who is in a coma. The client's Glascow Coma Scale is 6. Which response would the nurse expect the client to have?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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