Using the Glasgow Coma Scale, which number indicates that the patient is in a comatose state?

Answer and Explanation

The Correct Answer is D

A.   A GCS of 15 indicates full consciousness and alertness.
B.   A GCS of 12 indicates moderate impairment of consciousness.
C.   A GCS of 6 indicates severe impairment, but not necessarily comatose.
D.   A GCS of 8 or below is considered to indicate a comatose state.

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Correct Answer is D

Explanation

A. Partial-thickness skin loss with red tissue in wound bed: This is a characteristic of stage 2 pressure injuries, not stage 1.
B. Full thickness skin loss with visible adipose tissue: This is a characteristic of stage 3 pressure injuries.
C. Full thickness skin loss with visible bone: This is a characteristic of stage 4 pressure injuries.

D. Intact skin with localized erythema: This is the characteristic of stage 1 pressure injuries, which present as non-blanching erythema (redness) of intact skin.

A. Ask the client to identify scented aromas. B. Listen to the client's speech. C. Ask the client to clench his teeth. D. Ask the client to read a Snellen chart.

Correct Answer is D

Explanation

A. Ask the client to identify scented aromas: This assesses cranial nerve I (olfactory), not cranial nerve II.
B. Listen to the client's speech: This assesses cranial nerve IX and X (glossopharyngeal and vagus), not cranial nerve II.
C. Ask the client to clench his teeth: This assesses cranial nerve V (trigeminal), not cranial nerve II.
D. Ask the client to read a Snellen chart: This is the correct method for assessing cranial nerve II (optic), which is responsible for vision. The Snellen chart tests visual acuity.

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Using the Glasgow Coma Scale, which number indicates that the patient is in a comatose state?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve Il?

Correct Answer is D

Explanation

A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching?

When assessing a client's skin, the nurse finds freckles. How would the nurse document the lesions?

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve IlI?

When assessing lymph nodes on the face and neck, which of the following findings are concerning? Select all that apply.

A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?