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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.
B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.
C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.
D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.
Correct Answer is D
Explanation
A. High fever. – Incorrect. Fever can occur with infection but is not a hallmark sign of sickle cell crisis.
B. Constipation. – Incorrect. Constipation is not a defining symptom of sickle cell crisis.
C. Bradycardia. – Incorrect. Tachycardia, not bradycardia, is common due to pain and hypoxia.
D. Pain. – Correct Answer. Severe pain is the most common symptom of sickle cell crisis due to vaso-occlusion and ischemia.
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