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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Correct Answer is A

Explanation

A. Elective cardioversion is a procedure used to restore a normal heart rhythm by delivering a controlled electrical shock to the heart. It is generally used for patients with stable atrial or ventricular arrhythmias who do not respond to medication. In the case of stable VT, elective cardioversion might be considered if the arrhythmia is causing symptoms or if the patient’s condition changes
B. CPR is an emergency procedure used when a person’s heart has stopped beating (cardiac arrest) or when they are not breathing. It is not indicated for a stable VT because the patient is still stable and conscious, and CPR is not used for arrhythmias like VT in a stable patient.
C. Radiofrequency catheter ablation is a procedure used to destroy abnormal electrical pathways in the heart that cause arrhythmias. This is often used as a treatment for recurrent or persistent VT, especially if medication or cardioversion fails to manage the condition effectively. For a stable patient with VT, this treatment might be considered in the long-term management plan rather than as an immediate intervention.
D. Defibrillation is the use of an electrical shock to the heart to restore a normal rhythm in cases of life- threatening arrhythmias such as ventricular fibrillation or pulseless VT. It is not used for stable VT because the patient still has a pulse and is not in immediate danger of cardiac arrest

A. Flexion and internal rotation of upper extremities B. Flexion and external rotation of upper extremities C. Extension and internal rotation of upper extremities D. Extension and external rotation of upper extremities

Correct Answer is A

Explanation

A. This description accurately depicts decorticate posturing. The characteristic feature of decorticate posturing is the flexion of the upper extremities (arms) and the extension of the lower extremities (legs). The internal rotation of the legs is often observed in this posture. This pattern is seen in severe brain damage, particularly involving the corticospinal tract.
B. External rotation of the arms is not characteristic of decorticate posturing. In decorticate posturing, the arms are flexed and positioned close to the body, with internal rotation being more typical. Therefore, this option does not accurately describe decorticate posturing.
C. Extension of the arms is more characteristic of decerebrate posturing rather than decorticate posturing. Decerebrate posturing involves the extension of both the arms and legs. Internal rotation of the arms is not a typical feature of decerebrate posturing, so this choice does not describe decorticate posturing.
D. Extension and external rotation of the arms describe decerebrate posturing rather than decorticate posturing. Decerebrate posturing is characterized by the extension of the arms and legs, not flexion. Therefore, this option does not describe decorticate posturing.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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