A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client is unconscious.

The client is unable to make vocal sound.

The client can follow simple motor commands.

The client opens his eyes when spoken to.

Answer and Explanation

The Correct Answer is D

An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.

The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.

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Correct Answer is C

Explanation

To prevent autonomic dysreﬂexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreﬂexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.

a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreﬂexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreﬂexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreﬂexia.

A. Urinary retention B. Tinnitus C. Flank pain D. Bradycardia

Correct Answer is C

Explanation

The nurse should monitor the client for ﬂank pain as an adverse eﬀect of taking calcium carbonate. Calcium carbonate is a calcium supplement used to prevent or treat a calcium deficiency¹. One of the side eﬀects of calcium carbonate is the formation of kidney stones, which can cause ﬂank pain².

a. Urinary retention is not a common adverse eﬀect of calcium carbonate.
b. Tinnitus is not a common adverse eﬀect of calcium carbonate.
d. Bradycardia is not a common adverse eﬀect of calcium carbonate.

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A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Correct Answer is C

Explanation

A nurse is caring for a client who has osteoporosis and is taking calcium carbonate. The nurse should monitor the client for which of the following adverse eﬀects?

Correct Answer is C

Explanation

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