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 D
Explanation
A. Spinal cord degeneration is a general term for the deterioration of the spinal cord and doesn't specifically describe the patient's posture.
B. Decorticate posturing is characterized by the arms flexed and adducted, with the wrists and fingers flexed. The legs are extended and adducted, with the feet plantar flexed.
C. Atypical hyperreflexia refers to exaggerated reflexes, not a specific posture.
D. Decerebrate posturing is characterized by the arms extended and pronated, with the wrists and fingers flexed. The legs are stiffly extended with plantar flexion.
Correct Answer is A
Explanation
A. Tachycardia is a classic sign of the compensatory stage of shock. The body attempts to increase cardiac output by increasing heart rate to maintain blood pressure.
B. Hypokalemia is more likely to occur in the later stages of shock, as it's associated with tissue breakdown and renal dysfunction.
C. Mottled skin is a sign of the progressive stage of shock, indicating poor peripheral perfusion.
D. Blood pressure 115/68 mmHg: While this might be considered within normal range, it's important to consider the baseline blood pressure of the patient. In the compensatory stage, blood pressure may be maintained, but there are other compensatory mechanisms in place (like increased heart rate) to do so.
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