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 A
Explanation
The correct answer is choice A. Deep tendon reflexes 2+. This indicates that the client is receiving the therapeutic effect of magnesium sulfate, which is to prevent seizures by reducing neuromuscular excitability.
Magnesium sulfate is a mineral that is given intravenously to women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy, to reduce the risk of seizures or eclampsia. It can also prolong pregnancy for up to two days, allowing drugs that speed up the baby’s lung development to be administered.
Choice B is wrong because 1+ proteinuria via urine dipstick is not a therapeutic effect of magnesium sulfate, but a sign of preeclampsia.
Proteinuria indicates that the kidneys are not working properly and are leaking protein into the urine. Magnesium sulfate does not improve the outcomes for the baby and can cause side effects such as respiratory depression for the mother.
Choice C is wrong because pulse rate 100/min is not a therapeutic effect of magnesium sulfate, but a possible side effect.
Magnesium sulfate can cause vasodilation, which lowers blood pressure and increases heart rate. A normal pulse rate for an adult is between 60 and 100 beats per minute. A pulse rate higher than 100 beats per minute may indicate tachycardia, which can be caused by various factors such as anxiety, dehydration, fever, infection, or medication.
Choice D is wrong because urine output 20 mL/hr is not a therapeutic effect of magnesium sulfate, but a sign of kidney failure. A normal urine output for an adult is between 800 and 2000 mL per day, or about 30 to 80 mL per hour. A urine output lower than 30 mL per hour may indicate oliguria, which can be caused by various factors such as dehydration, blood loss, shock, or kidney damage. Magnesium sulfate can cause renal toxicity if given in high doses or for prolonged periods.
Correct Answer is D
Explanation
Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.
Choice A, acrocyanosis, is wrong because it is a normal finding in newborns.
Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.
Choice B, bradycardia, is wrong because it is not a typical sign of withdrawal.
Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.
Choice C, bulging fontanels, is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.
Normal ranges for newborn vital signs are as follows:
- Heart rate: 120 to 160 beats per minute
- Respiratory rate: 30 to 60 breaths per minute
- Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
- Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic
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