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When assessing a patient with a brain injury- using the Glasgow Coma Scale (GCS), the nurse gathers information regarding which of the following parameters?

Level of consciousness

Reflex activity

Sensory involvement

Cognitive ability

Answer and Explanation

The Correct Answer is A

A. Correct. The GCS assesses level of consciousness based on eye-opening, verbal response, and motor response.

B. Incorrect. Reflex activity is assessed separately using neurological reflex tests.

C. Incorrect. Sensory involvement is evaluated through different neurological exams, not the GCS.

D. Incorrect. Cognitive ability assessment requires specialized tests, such as the Mini-Mental State Examination (MMSE).

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Correct Answer is B

Explanation

A. Incorrect → Weight gain (even if minor) can indicate poor glucose control, especially if linked to fluid retention or insulin resistance.

B. Regular ophthalmology exams are crucial for early detection of diabetic retinopathy, a leading cause of blindness in diabetes. Scheduling an eye appointment demonstrates proactive disease management.

C. Incorrect → A Hemoglobin A1c of 8.1% is above the target range (typically <7% for diabetics) and indicates poor blood glucose control over the past 2-3 months.

D. Incorrect → A reddened area on the sole of the foot suggests early signs of diabetic foot complications and possible neuropathy or poor circulation, requiring intervention.

A. Double-check the product numbers on the PRBCS with the patient ID band. B. Monitor the patient for shortness of breath or chest pain during the transfusion. C. Obtain the temperature, blood pressure, and pulse before the transfusion. D. Verify the patient identification (ID) according to hospital policy.

Correct Answer is C

Explanation

A. Incorrect. Blood verification must be done by two licensed nurses.

B. Incorrect. Monitoring for transfusion reactions is the nurse's responsibility.

C. Correct. UAPs can obtain baseline vital signs before the transfusion, as long as the nurse interprets them.

D. Incorrect. Verifying patient ID for blood transfusions is a nursing responsibility per hospital protocol.

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When assessing a patient with a brain injury- using the Glasgow Coma Scale (GCS), the nurse gathers information regarding which of the following parameters?

Nursing Test Bank

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