Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Verbal respond

Motor respond

Pupillary responds

Gag Reflex

Eye Opening

Answer and Explanation

Correct Answer : A,B

A.   The verbal response is one of the three components of the Glasgow Coma Scale. It assesses the patient's ability to speak and respond appropriately to questions, indicating their level of consciousness. Responses are scored based on clarity, coherence, and relevance.
B.   Motor response is another component of the Glasgow Coma Scale. It evaluates the patient’s ability to move in response to stimuli, including purposeful movements, localizing pain, or abnormal posturing. The motor response helps gauge the patient’s level of consciousness and neurological function.
C.   Pupillary response refers to how the pupils react to light and changes in size. While important in neurological assessments, it is not one of the three components of the Glasgow Coma Scale. Pupillary response is assessed separately from the GCS but provides additional information about brain function and potential injury.
D.   The gag reflex is a protective mechanism to prevent choking and is assessed by stimulating the back of the throat. It is not included in the Glasgow Coma Scale. The GCS focuses on eye opening, verbal response, and motor response rather than reflexes.
E.   Eye opening is the third component of the Glasgow Coma Scale. It assesses the patient’s ability to open their eyes spontaneously or in response to stimuli. This component helps determine the level of consciousness and alertness.

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Correct Answer is A

Explanation

A. Lateral epicondylitis, commonly known as "tennis elbow," is an overuse injury characterized by pain and tenderness on the outer part of the elbow (lateral epicondyle). It results from repeated stress and

strain on the forearm muscles and tendons, often due to activities involving repetitive arm motions such as tennis. The pain typically worsens with activities involving gripping, extending, or lifting.
B. Rheumatoid arthritis (RA) is a chronic inflammatory disease that typically affects joints symmetrically, causing pain, swelling, and stiffness. It usually involves joints like the hands, wrists, and knees rather than the elbows alone. RA symptoms are generally more diffuse and persistent, rather than specifically linked to recent physical activity and localized pain associated with movement.
C. Gout is a form of arthritis caused by the accumulation of uric acid crystals in the joints. It often presents with sudden, severe pain, redness, and swelling, typically affecting the big toe but can also affect other joints. Gout attacks usually occur at night and are often very acute and localized. It is less likely to be associated with the type of pain described (pain during extension and flexion) and recent physical activity.
D. Medial epicondylitis, also known as "golfer’s elbow," is similar to lateral epicondylitis but affects the inner part of the elbow (medial epicondyle). It is more commonly associated with activities that involve gripping and wrist flexion rather than the generalized extension and flexion pain described.

A. Stationary soft palate on phonation B. Uvula and soft palate rising bilaterally C. Asymmetrical soft palate D. Deviation of uvula when client says "ah"

Correct Answer is B

Explanation

A. The soft palate should move during phonation. If it remains stationary, it could indicate a problem with cranial nerves IX and X. These nerves control the movement of the soft palate and the muscles involved in phonation.
B. This is the normal finding. During the assessment, when the patient says "ah," the uvula and soft palate should rise symmetrically. This movement indicates that cranial nerves IX and X are functioning properly. If the uvula and soft palate rise bilaterally, it means that both sides of the soft palate are being controlled correctly by these nerves.
C. Asymmetry in the soft palate could indicate dysfunction of cranial nerves IX and X. Normally, the soft palate should rise evenly on both sides when the patient says "ah." An asymmetrical soft palate suggests that one side is not functioning correctly, which may be due to nerve damage or weakness.
D. This is not a normal finding. If the uvula deviates to one side when the patient says "ah," it indicates a problem with the function of the cranial nerves. The deviation is usually towards the side opposite to the weak or affected side. This asymmetry in uvula movement can be due to a weakness or paralysis of the muscles on one side controlled by these nerves.

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Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

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Naxlex Comprehensive Predictor Exams

A 75-year-old male patient who recently started playing Tennis at the local adult care center is complaining of elbow pain associated with extension and flexion range of movement. The nurse knows the likely cause of this patient discomfort is due to:

Correct Answer is A

Explanation

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

Correct Answer is B

Explanation

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

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Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

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