The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What will the nurse do next?

Re-assess in 15 minutes

Ask the patient to open eyes on command

Document the findings

Notify the physician

Answer and Explanation

The Correct Answer is C

A) Re-assess in 15 minutes: While regular assessments are important in a neurological evaluation, if the Glasgow Coma Scale (GCS) score is 15, indicating the patient is fully alert and oriented, there may not be an immediate need to re-assess so soon unless the patient's condition changes.

B) Ask the patient to open eyes on command: If the GCS score is already determined to be 15, this indicates that the patient is responsive and capable of opening their eyes spontaneously. Asking the patient to open their eyes is unnecessary in this context since the score already reflects full responsiveness.

C) Document the findings: Documenting the GCS score of 15 is crucial as it establishes a baseline for the patient’s neurological status. This documentation is essential for ongoing assessments and monitoring, providing a record of the patient’s condition at this moment.

D) Notify the physician: Notifying the physician is not required for a GCS score of 15, as this score indicates a normal level of consciousness. Communication with the physician would be warranted only if there were changes in the patient's condition or a lower GCS score observed.

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Correct Answer is D

Explanation

A) Splint and immobilize the extremity: While immobilizing the injured extremity is important to prevent further injury, it should follow an initial assessment of blood flow and nerve function to ensure there are no vascular or neurological compromises.

B) Apply an ice pack to the ankle: Applying ice can help reduce swelling and alleviate pain. However, it is essential first to assess the circulation to the limb to ensure that applying ice will not worsen any underlying issues.

C) Encourage weight bearing and ambulation: Encouraging weight bearing on a potentially injured ankle can lead to further damage and is not appropriate. The priority is to assess the injury and understand its severity.

D) Assess pulse, color, temperature, and capillary refill: This step is crucial as it evaluates the vascular status of the limb. Assessing these factors helps identify any potential complications, such as compartment syndrome or inadequate blood flow, and guides further management of the injury.

A. "I have cut back on fat and switched to a vegetarian diet." B. "I have cut back on my smoking." C. "I have been stressed out since my divorce last year." D. "I have an occasional glass of wine." E. "I have gained 25 pounds over the past year."

Correct Answer is ["C","E"]

Explanation

A) "I have cut back on fat and switched to a vegetarian diet." This statement suggests a positive change in dietary habits, which can lower the risk of cardiovascular disease. A vegetarian diet, particularly if it includes plenty of fruits, vegetables, and whole grains, is associated with a reduced risk of heart disease. Therefore, this statement does not indicate an increased risk.

B) "I have cut back on my smoking." While reducing smoking is a positive step, smoking itself is a significant risk factor for cardiovascular disease. However, the statement indicates an attempt to decrease risk, which does not inherently suggest an increased risk. It may show improvement rather than risk.

C) "I have been stressed out since my divorce last year." Chronic stress is a recognized risk factor for cardiovascular disease, as it can lead to behaviors such as poor diet, inactivity, and increased blood pressure. This statement highlights a significant concern for the client’s cardiovascular health.

D) "I have an occasional glass of wine." Moderate alcohol consumption is sometimes associated with cardiovascular benefits. While excessive drinking can pose risks, this statement alone does not indicate an increased risk of cardiovascular disease. It reflects moderation rather than concern.

E) "I have gained 25 pounds over the past year." Weight gain, especially if it leads to obesity, is a significant risk factor for developing cardiovascular disease. This statement indicates a change in health status that could negatively impact the client’s cardiovascular risk profile.

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The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What will the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is in the ED after falling off a ladder. His ankle appears swollen, out of alignment, and is painful to touch. What will the nurse do first?

Correct Answer is D

Explanation

The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply.

Correct Answer is ["C","E"]

Explanation

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