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

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. The primary purpose of a halo fixation device is to immobilize the cervical spine to prevent further injury and promote healing.
B. The halo device provides rigid immobilization of the cervical spine.
C. This is incorrect and dangerous. The screws in the halo device should only be tightened by a healthcare professional.
D. Applying talcum powder under the halo vest can actually increase the risk of skin breakdown. The area should be kept clean and dry.

A. Obtain a wound culture. B. Administer broad-spectrum antibiotics. C. Rapidly administer 30 mL/kg of normal saline. D. Insert a nasogastric (NG) tube. E. Type and cross-match for 2 units of packed RBCs F. Obtain a urine specimen. G. Measure lactate level. H. Obtain blood cultures

Correct Answer is ["B","C","G","H"]

Explanation

A. Obtain a wound culture: While important, it is not the immediate priority compared to fluid resuscitation, antibiotic administration, and lactate level measurement.
B. Early administration of antibiotics is crucial in sepsis management to prevent further tissue damage and organ dysfunction.
C. Fluid resuscitation is essential to improve blood pressure and organ perfusion. Rapid administration of fluids is necessary to stabilize the patient.
D. Inserting a nasogastric (NG) tube might be necessary later if the patient develops gastrointestinal issues, but it's not an immediate priority.

E. While blood transfusion might be necessary if the patient becomes severely hypotensive, it's not the initial step. Fluid resuscitation is attempted first.
F. Urine culture can be helpful in identifying the source of infection but is not the immediate priority.
G. Lactate levels are a biomarker for tissue hypoxia and can help assess the severity of sepsis.
H. Blood cultures are essential to identify the causative organism for targeted antibiotic therapy.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Correct Answer is ["B","C","G","H"]

Explanation

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?

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Exhibits A nurse is caring for a client who has a seizure disorder. (Select all that apply.)

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

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A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?

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