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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
Therefore, this client is most likely to be stable and ready for early discharge.
Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).
This client is not a good candidate for early discharge.
Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
This client is not a good candidate for early discharge.
Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).
COP
Correct Answer is A
Explanation
Choice A reason:
Measuring the arm circumference above the insertion site daily is appropriate. When planning care for a client scheduled to receive a peripherally inserted central catheter (PICC) in the arm, it is appropriate for the nurse to include measuring the arm circumference above the insertion site daily. This intervention is essential to monitor for any signs of complications, such as edema or swelling, which could indicate thrombosis or infiltration at the insertion site.
Choice B reason:
Administering sedation Administering sedation is not a routine intervention for a PICC insertion procedure is inappropriate. Sedation might be considered for certain procedures, but it is not typically used for PICC insertions. PICC insertions are generally performed with local anaesthesia at the insertion site.
Choice C reason:
Scheduling an MRI post procedure to verify placement An MRI is not typically used to verify the placement of a PICC. The placement of a PICC is usually confirmed using X-ray or other imaging methods that can visualize the catheter's location within the central veins. Post-procedure verification of PICC placement is essential to ensure proper positioning and to prevent complications.
Choice D reason:
Using gauze to secure an arm board to the involved extremity Using gauze to secure an arm board to the involved extremity is not a common practice for securing a PICC. After a PICC insertion, a securement device specifically designed for PICCs is typically used to secure the catheter in place and prevent movement.
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