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","D","E"]

Explanation

A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke

A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is a genetic disorder involving a vitamin K deficiency." D. "DIC is caused by abnormal coagulation involving fibrinogen."

Correct Answer is D

Explanation

A. Heparin can be used to manage DIC but it's not a lifelong treatment and is part of a complex management plan.
B. DIC actually leads to a decreased platelet count due to excessive clotting.
C. DIC is an acquired condition, not a genetic one, and while vitamin K is involved in clotting, it's not the primary cause of DIC.
D. DIC is a complex disorder involving uncontrolled clotting and bleeding due to the depletion of clotting factors, including fibrinogen.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is D

Explanation

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