A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client’s Glasgow coma scale rating is 15.
Which of the following findings should the nurse expect?
The client withdraws from pain.
The client is unable to obey commands.
The client opens eyes to sound.
The client is oriented times three.
The Correct Answer is D
This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.
Choice A is wrong because the client withdraws from pain.
This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.
Choice B is wrong because the client is unable to obey commands.
This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.
Choice C is wrong because the client opens eyes to sound.
This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.
The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.
It consists of three tests: eye opening, verbal response, and motor response.
Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A firewall is a system that protects the network from unauthorized access and prevents data breaches. A firewall is essential for ensuring the confidentiality, integrity, and availability of electronic health records.
Choice A is wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security.
Choice B is wrong because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system.
Choice C is wrong because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know.
Correct Answer is C
Explanation
This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas. This also gives a more peaceful appearance to the client’s body for the family visit.
Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.
Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.
Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.
Normal ranges are not applicable for this question as it does not involve any physiological measurements.
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