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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pacemaker spikes with each T wave indicates a malfunctioning pacemaker.
B. Pacemaker spikes before each P wave would indicate atrial pacing, not ventricular pacing.
C. A ventricular pacemaker stimulates the ventricles to contract, so the pacing spike should precede the QRS complex.
D. Pacemaker spikes after each QRS complex would indicate a malfunctioning pacemaker.
Correct Answer is D
Explanation
A. To convert atrial fibrillation to sinus rhythm is the function of anti-arrhythmic medications, not anticoagulants like dabigatran.
B. This is the role of thrombolytic medications, not anticoagulants.
C. This is the function of beta-blockers or calcium channel blockers.
D. Dabigatran is an anticoagulant primarily used to prevent stroke in patients with atrial fibrillation by preventing blood clot formation.
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