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
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.
Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).
Correct Answer is ["B","C","D"]
Explanation
B, C, and D. These findings require follow-up because they indicate possible complications of chemotherapy, such as infection, low blood cell counts, and lung damage.
Choice B is correct because a temperature of 38.6° C (101.5° F) is a sign of fever, which can indicate an infection. Chemotherapy can weaken the immune system and make the client more prone to infections.
Choice C is correct because a WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3 and indicates leukopenia, a condition of low white blood cells. Chemotherapy can cause leukopenia by damaging the bone marrow where blood cells are produced.
Choice D is correct because crackles heard at the bases of the lungs are abnormal breath sounds that can indicate fluid accumulation or inflammation in the lungs. Chemotherapy can cause lung damage by affecting the cells that line the airways or by triggering an immune response.
Choice A is wrong because a potassium level of 3.6 mEq/L is within the normal range of 3.5 to 5 mEq/L and does not require follow-up.
Choice E is wrong because a blood pressure of 114/56 mm Hg is within the normal range of less than 120/80 mm Hg and does not require follow-up.
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