Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because monitoring the client's electrolyte levels is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice B Reason: This is correct because suctioning saliva from the client's mouth is the highest priority, as it prevents airway obstruction and aspiration, which can lead to respiratory distress and infection.
Choice C Reason: This is incorrect because recording the client's intake and output is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice D Reason: This is incorrect because performing passive range of motion on each extremity is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.

Correct Answer is B
Explanation
Choice A Reason: This is incorrect because the client is not unconscious, as the GCS score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.
Choice B Reason: This is correct because the client can follow simple motor commands, as the GCS score for best motor response is 5, which means the client can localize pain by moving his limbs away from the source of stimulation.To interpret the Glasgow Coma Scale (GCS) score provided in the scenario:Eye Opening (E): 3 - The client opens their eyes in response to verbal stimuli.Best Verbal Response (V): 5 - The client is oriented and able to engage in coherent conversation.Best Motor Response (M): 5 - The client can localize pain or follow motor commands (depending on additional context). The total GCS score would be 3 + 5 + 5 = 13, indicating a mild level of impairment or responsiveness.
Choice C Reason: This is incorrect because the client is able to make vocal sounds, as the GCS score for best verbal response is 5, which means the client can orient himself to person, place, and time.
Choice D Reason: This is incorrect because the client does not open his eyes when spoken to, as the GCS score for eye opening is 3, which means the client only opens his eyes in response to pain.

