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
The correct answer is choice C: Document the client’s behavior prior to being placed in seclusion.
Choice A rationale:
Discussing with the client his inappropriate behavior prior to seclusion is important, but it’s not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client’s behavior prior to seclusion.
Choice B rationale:
Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context.
Choice C rationale:
Documenting the client’s behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention.
Choice D rationale:
Assessing the client’s behavior once every hour is important to monitor the client’s condition and response to seclusion. However, this is not the most appropriate action in this context.
Correct Answer is D
Explanation
This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.
Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.
Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.
Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.
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