A patient with a head injury opens his eyes to verbal stimulation, shouts out when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?
9
11
15
13
The Correct Answer is A
Choice A Reason: This is correct because the patient's Glasgow Coma Scale score is 9. The Glasgow Coma Scale is a tool that assesses the level of consciousness of a patient with a head injury by measuring three parameters: eye opening, verbal response, and motor response. The patient's eye opening score is 3 (opens eyes to verbal command), verbal response score is 4 (confused speech), and motor response score is 2 (withdraws from pain). The total score is the sum of these three scores, which is 9.
Choice B Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 11. To get a score of 11, the patient would need to have a higher motor response score, such as 4 (withdraws to touch) or 5 (localizes to pain).
Choice C Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 15. To get a score of 15, the patient would need to have the highest scores for all three parameters, such as 4 (opens eyes spontaneously), 5 (oriented speech), and 6 (obeys commands).
Choice D Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 13. To get a score of 13, the patient would need to have a higher verbal response score, such as 5 (oriented speech).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
The correct answers are b, d, and e.
Choice A: Slurred speech.
Slurred speech can be associated with increased ICP due to the pressure effects on the brain areas responsible for speech production. However, it is not typically considered a late sign of increased ICP. It may occur earlier in the progression as the brain's ability to coordinate muscle movements is affected.
Choice B: Bradycardia with a bounding pulse.
Bradycardia with a bounding pulse is a classic sign of Cushing's triad, which is a late and ominous sign of significantly increased ICP. It indicates that the body is attempting to increase arterial blood pressure to overcome the increased ICP and maintain cerebral perfusion. The normal range for adult heart rate is 60-100 beats per minute.
Choice C: Confusion.
Confusion can be an early sign of increased ICP as it can indicate changes in cerebral function. However, it is not specifically a late sign of increased ICP. Early signs of increased ICP can include headache, nausea, and confusion, as the brain is initially responding to the pressure changes.
Choice D: Hypertension with an increasing pulse pressure.
Hypertension with an increasing pulse pressure is another component of Cushing's triad. It reflects the body's compensatory mechanism to preserve cerebral blood flow in the face of rising ICP. An increasing pulse pressure (the difference between systolic and diastolic blood pressure) is a late sign of increased ICP. Normal pulse pressure is typically 30-40 mm Hg.
Choice E: Nonreactive dilated pupils.
Nonreactive dilated pupils are a late sign of increased ICP and indicate pressure on the cranial nerves that control pupil size and reaction to light. This is a grave sign and often indicates impending brain herniation.
Choice F: Hypotension with a decreasing pulse pressure.
Hypotension with a decreasing pulse pressure is not typically associated with increased ICP. In fact, hypertension with a widening pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
Correct Answer is A
Explanation
Choice A Reason: This is the correct choice. Washing towels, sheets, and pillowcases is a home care instruction that the nurse will offer to the client, as it prevents reinfection and transmission of bacteria or viruses. The client has conjunctivitis, which is inflammation of the conjunctiva or thin membrane that covers the white part of the eye and lines the eyelids. It can be caused by bacteria, viruses, allergies, or irritants.
Choice B Reason: This is an incorrect choice. Using antifungal drops 3 times a day is not a home care instruction that the nurse will offer to the client, as it is not effective for conjunctivitis. Antifungal drops are used for fungal infections of the eye, which are rare and usually occur after trauma or surgery. The client may need antibiotic or antiviral drops, depending on the cause of conjunctivitis.
Choice C Reason: This is an incorrect choice. Scheduling a sexually transmitted infection (STI/STD) exam is not a home care instruction that the nurse will offer to the client, as it is not relevant for conjunctivitis. STIs can affect the eyes, but they usually cause different symptoms, such as redness, pain, or discharge from the urethra or vagina. The client may need to be tested for STIs if they have other risk factors or signs of infection.
Choice D Reason: This is an incorrect choice. Avoiding going outside during daylight hours is not a home care instruction that the nurse will offer to the client, as it is not necessary for conjunctivitis. The client may experience sensitivity to light, but they can wear sunglasses or avoid direct sunlight to protect their eyes. The client should also avoid rubbing or touching their eyes, wear glasses instead of contact lenses, and discard any eye makeup or cosmetics that may be contaminated.
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