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. Apply warm compresses to site of the client's pacemaker insertion: Heat application is contraindicated as it may increase swelling or risk infection.

B. Teach the client to avoid being near any type of household microwave oven: Modern pacemakers are shielded, so microwaves do not interfere with their function.

C. Ambulate the client as soon as possible to evaluate pacemaker function: While early ambulation is encouraged, pacemaker function is not evaluated through ambulation.

D. Instruct client to limit movement of the arm on side where pacemaker was inserted: Limiting arm movement prevents dislodging the pacemaker leads during the healing phase.

A. Complete a neurovascular check of the affected extremity. B. Perform passive range of motion. C. Assess the gag reflex prior to feeding the client. D. Keep the client in high Fowler's position.

Correct Answer is A

Explanation

A. Complete a neurovascular check of the affected extremity: Neurovascular assessment ensures that blood flow and nerve function are intact post-procedure. Complications such as arterial occlusion or hematoma can cause ischemia or nerve damage, making this the priority.

B. Perform passive range of motion: This is not a priority and may not be appropriate immediately post-catheterization as movement of the extremity can increase the risk of bleeding.

C. Assess the gag reflex prior to feeding the client: This applies to clients recovering from sedation during procedures like endoscopy, not cardiac catheterization.

D. Keep the client in high Fowler's position: This is contraindicated post-cardiac catheterization, as elevating the head too much can increase pressure at the puncture site and lead to bleeding.

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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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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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