A nurse assesses a client with a brain injury. The client opens his eyes when the nurse calls his name, does not understand questions, and brings his arm up in response to a trapezius squeeze by the nurse. How would the nurse document this client's assessment using the Glasgow Coma Scale shown below
8
1
3
9
The Correct Answer is D
The client opens his eyes in response to voice, which scores 3 on the eye-opening part of the GCS.
Since the client does not understand questions, this would likely score 1 for verbal response, indicating incomprehensible sounds.
The motor response of bringing an arm up to a trapezius squeeze is localizing pain, which would score 5.
Therefore, the nurse would document the client's GCS score as E3V1M5, which totals to 9 out of a possible 15 points.
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Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Bradycardia is not a typical symptom of meningitis. Instead, meningitis is more likely to cause tachycardia (increased heart rate) as part of the body's response to fever and infection. Bradycardia would not be an expected sign in this context.
B. Fever and chills are common symptoms of meningitis. The infection and inflammation associated with meningitis can cause an elevated body temperature as the body responds to the infection.
C. Nuchal rigidity is a classic sign of meningitis. The inflammation of the meninges causes muscle stiffness and discomfort when trying to bend the neck forward, which is a common finding in this condition.
D. Severe headache is a common symptom of meningitis. The inflammation and irritation of the meninges often result in intense and persistent headaches, which can be one of the primary complaints of patients with meningitis.
E. Brudzinski's sign is a classic clinical sign of meningitis. It indicates meningeal irritation and is often assessed along with other signs to help diagnose meningitis.
Correct Answer is B
Explanation
A. This is a late sign of shock. It occurs when the body's compensatory mechanisms fail to maintain blood pressure.
B. This is one of the earliest signs of shock. The body tries to compensate for decreased oxygen delivery by increasing the respiratory rate.
C. This is a very late sign of shock, indicating severe kidney damage due to decreased blood flow.
D. This is also a late sign of shock, occurring when the brain is deprived of oxygen.
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