A nurse is preparing to perform a neurological assessment on a client who has a head injury.
Which of the following tools should the nurse use to assess the client's level of consciousness?
Glasgow Coma Scale (GCS)
Mini-Mental State Examination (MMSE)
Confusion Assessment Method (CAM)
Morse Fall Scale (MFS)
The Correct Answer is A
The Glasgow Coma Scale (GCS) is a tool that measures the level of consciousness based on three parameters: eye opening, verbal response, and motor response. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness.
Incorrect options:
B) Mini-Mental State Examination (MMSE) - This is a tool that measures cognitive function, such as orientation, memory, attention, and language. It is not used to assess level of consciousness.
C) Confusion Assessment Method (CAM) - This is a tool that screens for delirium, which is an acute and fluctuating disturbance of cognition and attention. It is not used to assess level of consciousness.
D) Morse Fall Scale (MFS) - This is a tool that assesses the risk of falling in hospitalized clients based on six factors: history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. It is not used to assess level of consciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client's chest x-ray shows clear lung fields.
Rationale: A chest x-ray is a diagnostic test that can confirm the presence or absence of pneumonia by showing areas of consolidation or infiltration in the lung tissue. A clear chest x-ray indicates resolution of pneumonia and effectiveness of treatment.
Incorrect options:
A) The client's temperature is 37.2°C (99°F). - This is a normal finding, but it does not rule out pneumonia as some clients may have low-grade fever or no fever at all with pneumonia.
B) The client's white blood cell count is 12.5 x 10^9/L. - This is an elevated finding, as the normal range for white blood cell count is 4.5 to 11 x 10^9/L. An elevated white blood cell count indicates inflammation or infection and does not reflect the effectiveness of treatment.
C) The client's oxygen saturation is 95% on room air. - This is a normal finding, as the normal range for oxygen saturation is 95% to 100%. However, it does not indicate the severity or resolution of pneumonia, as some clients may have normal oxygen saturation despite having pneumonia.
Correct Answer is D
Explanation
The nurse should ask open-ended questions that cover the characteristics, duration, frequency, severity, precipitating and relieving factors, associated symptoms, and impact of the cough on the client's health and quality of life.
Incorrect options:
A) "How long have you had this cough?" - This is a correct question, but it is not the only question that should be asked.
B) "What do you think is causing your cough?" - This is a correct question, but it is not the only question that should be asked.
C) "How does your cough affect your daily activities?" - This is a correct question, but it is not the only question that should be asked.
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