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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Related Questions
Correct Answer is C
Explanation
A. Milk and turkey slices. – Incorrect. Milk can inhibit iron absorption, and turkey is not a rich source of iron.
B. Fish and cottage cheese. – Incorrect. Cottage cheese is low in iron, and while some fish contain iron, they are not the best sources.
C. Spinach and beef. – Correct Answer. Both are excellent sources of iron, which helps improve hemoglobin levels in iron-deficiency anemia.
D. Yogurt and mozzarella. – Incorrect. Dairy products do not provide significant iron and may inhibit its absorption.
Correct Answer is B
Explanation
A. Incorrect → Insulin injections should be administered at a 90-degree angle unless the patient has minimal subcutaneous fat, in which case a 45-degree angle is used. A 25-degree angle is too shallow and may lead to improper absorption.
B. Rotating insulin injection sites helps prevent lipodystrophy and ensures consistent absorption. The patient’s decision to inject in the thigh after using the abdomen in the morning demonstrates proper site rotation.
C. Incorrect → Insulin should be administered with a U-100 insulin syringe (not a 1 mL syringe) to ensure accurate dosing.
D. Incorrect → While injecting an inch away from a previous site is reasonable, the preferred practice is rotating between different anatomical sites to prevent tissue damage and inconsistent absorption.
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