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. There can be slight variations in pupil size but the difference described (one pupil enlarged and fixed, the other constricted and reactive to light) is not considered normal.
B. Age-related changes in pupil size typically involve a gradual decrease in pupil size, not a sudden and dramatic difference between the two eyes.
C. Unequal pupil size, especially when one pupil is fixed and dilated, is a classic sign of increased intracranial pressure (ICP), often caused by head trauma.
D. Exposure to light would cause both pupils to constrict, not one to dilate and fix.
Correct Answer is D
Explanation
A. Jerking contractions of the head and neck is more indicative of seizures or other neurological conditions.
B. Pinpoint pupils can be associated with various conditions, including opioid overdose or pontine hemorrhage, but it's not specifically related to Babinski's sign.
C. Pronation of the arms is a general assessment finding, not specifically indicative of a neurological issue.
D. Dorsiflexion of the great toe is the classic response for Babinski's sign. It is an abnormal reflex indicating upper motor neuron damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today