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

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. The client is oriented times three.

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.

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Correct Answer is D

Explanation

the correct answer isd. Your desire to be an organ donor must be documented in writing.This is because organ donation is a legal and medical process that requires your consent and documentation 1. Some of the other options are incorrect or misleading. Here are some explanations:

A. Encourage a maximum fluid intake of 1,500 mL per day. B. Increase the amount of refined grains in the client’s diet. C. Provide the client with a cold drink prior to defecation. D. Administer a cathartic suppository 30 min prior to scheduled defecation times.

Correct Answer is D

Explanation

The correct answer is choice D. Administer a cathartic suppository 30 min prior to scheduled defecation times. This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or reflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A

bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.

Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.

Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.

Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injury.

Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.

Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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