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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 A

Explanation

A. Correct. Moving objects prevents injury during a seizure.

B. Incorrect. The patient should be placed on their side to maintain airway patency.

C. Incorrect. Restraining the patient can cause injury.

D. Incorrect. Never insert anything into a seizing patient’s mouth, as it can obstruct the airway or break teeth.

A. 8 hr B. 6 hr C. 4 hr D. 2 hr

Correct Answer is C

Explanation

A. 8 hr – Incorrect. RBC transfusions must not exceed 4 hours due to the risk of bacterial growth and hemolysis.

B. 6 hr – Incorrect. Blood products should be infused within a maximum of 4 hours to prevent complications.

C. 4 hr – Correct Answer. The maximum infusion time for packed RBCs is 4 hours to reduce the risk of bacterial contamination and infection.

D. 2 hr – Incorrect. While blood is often infused within 2 hours, the maximum safe limit is 4 hours.

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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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