The nurse is performing a neurologic assessment of a 41-year-old patient the patient is able to open eyes to pain, uses inappropriate words, and has flexion withdrawal from pain. What is their GCS score?

Answer and Explanation

The Correct Answer is A

The Glasgow Coma Scale (GCS) measures three aspects: Eye response, verbal response, and motor response.

Eye response: Opens eyes to pain (score 2).

Verbal response: Uses inappropriate words (score 3). Motor response: Flexion withdrawal from pain (score 4). Total GCS = 2 (eyes) + 3 (verbal) + 4 (motor) = 9.

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Correct Answer is B

Explanation

A. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane is not a typical finding, as the tympanic membrane should be pearly gray.
B. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane is the expected finding for a normal ear exam, showing the healthy tympanic membrane and the proper positioning of the cone of light.
C. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane is incorrect, as the tympanic membrane should be pearly gray, not pink and moist.
D. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane is an incorrect positioning of the cone of light (should be at 7 o'clock for the right ear and 5 o'clock for the left).

A. “As a nurse, I am required by law to report suspected child abuse.” B. "I reported the incident to my supervisor who decided to contact the authorities." C. "The provider will be coming to explain the situation." D. ”I am unable to discuss this, but I can contact my supervisor to speak with you."

Correct Answer is A

Explanation

A. The nurse is legally obligated to report suspected child abuse according to mandatory reporting laws. This response directly addresses the nurse’s legal responsibility without providing unnecessary details to the parents.
B. Reporting the incident to a supervisor does not fully address the nurse's legal obligation, which is to report the abuse to the authorities.
C. It is inappropriate to defer to the provider in this case, as the nurse holds the legal responsibility to report the suspicion.
D. The nurse should not avoid the discussion but instead provide a clear, legal explanation for their actions.

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The nurse is performing a neurologic assessment of a 41-year-old patient the patient is able to open eyes to pain, uses inappropriate words, and has flexion withdrawal from pain. What is their GCS score?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining a patient's ears, which of the following findings is considered the expected findings?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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