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 anticipatory guidance is a type of health teaching that involves sharing information and experiences through educational activities designed to improve health knowledge, attitudes, behaviors, and skills. Anticipatory guidance helps parents to prevent or reduce health problems in their children by providing them with information on topics such as nutrition, immunization, injury prevention, and developmenta milestones. Providing anticipatory guidance classes through public schools is an example of a population-based public health intervention that aims to improve the health of a large group of people who share common characteristics or risks.
Choice A is wrong because tertiary health interventions are not the best way to improve health for the local population. Tertiary health interventions are those that focus on treating and rehabilitating people who have already developed a disease or disability. They are more costly and less effective than primary or secondary health interventions, which aim to prevent or detect diseases early.
Encouraging rural residents to focus health spending on tertiary health interventions would not address the underlying causes of poor health in the community.
Choice B is wrong because having a nurse from outside the community provide health lectures at the county hospital is not a culturally appropriate or accessible way to deliver health education. A nurse from outside the community may not understand the needs, values, beliefs, and practices of the rural residents, and may not be able to establish trust and rapport with them. Moreover, the county hospital may not be a convenient or comfortable location for many rural residents to attend health lectures, especially if they have transportation, financial, or time barriers.
A better approach would be to involve local community members and leaders in planning and delivering health education programs that are tailored to the rural context and culture.
Choice D is wrong because launching a media campaign to increase awareness about industrial pollution is not a sufficient action to improve health for the local population. While increasing awareness is an important first step, it does not necessarily lead to behavior change or environmental improvement.
A media campaign alone would not address the sources and effects of industrial pollution, nor would it provide solutions or resources for the rural residents to protect themselves from exposure.
A more comprehensive action would be to collaborate with other stakeholders, such as environmental agencies, industry representatives, and community groups, to develop and implement strategies for reducing and monitoring industrial pollution and its impact on the environment.
Correct Answer is D
Explanation
This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.
The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.
The nurse should use assistive devices that are appropriate for the client’s condition and weight.
Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.
The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
The nurse should also involve the client in the care plan and respect their preferences whenever possible.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.