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 B

Explanation

The correct answer is choice B. Isolate the client from staff who are pregnant. Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage. Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure. Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate. Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.

A. Weight loss B. Muscle weaknesss C. Fever D. Edema

Correct Answer is B

Explanation

Choice A reason

Weight loss is not the correct answer: Weight loss is not a common side effect of simvastatin. In fact, weight loss is generally not associated with statin use. If the client experiences significant, unintentional weight loss, it may indicate another underlying issue that should be reported to the provider.

Choice B reason:

Muscle weakness is the correct answer. The nurse should instruct the client to monitor and report any muscle weakness to the healthcare provider when taking simvastatin. Simvastatin is a statin medication used to lower cholesterol levels in the blood. While statins are generally well-tolerated, they can occasionally cause muscle-related side effects, including muscle weakness or pain.

Rhabdomyolysis, a severe condition characterized by the breakdown of muscle fibres, is a rare but serious side effect of statin use. Muscle weakness may be an early sign of this condition. Therefore, if the client experiences any unexplained or persistent muscle weakness while taking simvastatin, it should be reported to the healthcare provider immediately.

Choice C reason

Fever is not the correct answer: Fever is not a common side effect of simvastatin. If the client develops a fever while taking simvastatin, it is more likely to be related to another condition and should be reported to the provider for further evaluation.

Choice D reason:

Edema is the correct answer: Edema (swelling) is not a common side effect of simvastatin. If the client experiences significant edema, especially in the extremities, it may indicate another underlying issue that should be reported to the provider.

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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

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A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

Correct Answer is B

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