What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

Vocalization, strength, and pupillary response and accommodation

Eye opening. verbal response, and motor response

Pupillary reaction, eye opening, and motor response

Motor response. sensory response, and level of consciousness

Answer and Explanation

The Correct Answer is B

A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.

B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.

C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.

D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.

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

Explanation

A. A
Patients with A- blood type have A antigens on their red blood cells and do not have the Rh factor (negative). They can receive A- blood because it has the same antigens and Rh factor, making it a perfect match.

B. O+
Rh-negative clients cannot receive Rh-positive blood, as it may trigger an immune reaction.

C. AB-
Type AB blood contains A and B antigens, which A- individuals do not naturally have, increasing the risk of a transfusion reaction.

D. A+
A Rh-negative (A-) client cannot receive Rh-positive (A+) blood due to the risk of Rh sensitization.

E. O-
O- blood is the universal donor for red blood cells, meaning it contains no A, B, or Rh antigens, making it safe for an A- recipient.

A. Laterally on the left side with a pillow under the head and the right arm and hand hyperextended B. Supine with a pillow under the head, and elevate the right hand and arm on a pillow C. Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillow D. Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Correct Answer is C

Explanation

A. Laterally on the left side

Lateral positioning may not fully prevent contractures.

B. Supine with a pillow under the head

A pillow under the head can cause neck contractures.

C. Semi-Fowler’s without a pillow, right arm & hand elevated

Prevents contractures and promotes drainage of edema.

D. Prone without a pillow

Prone position increases discomfort and risk of respiratory complications.

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What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

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

Explanation

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Correct Answer is C

Explanation

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