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 C
Explanation
This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs. If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.
Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.
Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.
Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.
Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.
A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.
Correct Answer is ["C","E"]
Explanation
A urine culture is indicated for the client who has lower back pain and pinkish vaginal discharge, as these symptoms may suggest a urinary tract infection (UTI). A urine culture can identify the causative organism and guide the appropriate antibiotic therapy.
Phenazopyridine is a urinary analgesic that can relieve pain, burning, and urgency associated with a UTI. However, it requires a provider prescription and should not be used for more than two days.
A vaginal culture is not necessary for this client, as the vaginal discharge is likely due to the cervical changes during labor. A vaginal culture may be indicated for clients who have signs of vaginitis, such as itching, odor, or abnormal color of the discharge.
Obtaining a provider prescription for antibiotics is premature for this client, as the urine culture results are not available yet. Antibiotics should be prescribed based on the sensitivity of the organism causing the UTI.
Ibuprofen 600 mg every 6 hr for mild to moderate pain is not appropriate for this client, as it may interfere with uterine contractions and prolong labor. Ibuprofen is also contraindicated in the third trimester of pregnancy due to the risk of premature closure of the ductus arteriosus in the fetus. The nurse should use nonpharmacological methods to relieve the client’s back pain, such as massage, heat, or position changes.
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