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?

Answer and Explanation

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).

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Correct Answer is A

Explanation

Choice A Reason: This is correct because macular degeneration is a condition that affects the macula, which is the central part of the retina that is responsible for sharp and detailed vision. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field.

Choice B Reason: This is incorrect because glaucoma is a condition that affects the optic nerve, which is the nerve that connects the eye to the brain and carries visual signals. Glaucoma can cause increased pressure inside the eye, damage to the optic nerve, and loss of peripheral vision.

Choice C Reason: This is incorrect because diabetic retinopathy is a condition that affects the blood vessels in the retina, which is the layer of tissue at the back of the eye that converts light into nerve impulses. Diabetic retinopathy can cause bleeding, swelling, or leakage of fluid in the retina, and loss of vision in any part of the visual field.

Choice D Reason: This is incorrect because cataract is a condition that affects the lens, which is the transparent structure behind the pupil that focuses light onto the retina. Cataract can cause clouding or opacity of the lens, and reduced vision in all parts of the visual field.

A. The test assesses for sun protection factor B. The test is inconclusive C. The presence of erythema indicates you are allergic to the allergen D. The areas that did not turn red indicate low risk for skin cancer

Correct Answer is C

Explanation

Choice A Reason: The test does not assess for sun protection factor, but rather for contact dermatitis. Sun protection factor is a measure of how well a sunscreen protects the skin from ultraviolet radiation, which can cause sunburn and skin damage.

Choice B Reason: The test is not inconclusive, but rather positive for some allergens and negative for others. The test involves applying small patches of different substances to the skin and observing for any reactions after 48 hours.

Choice C Reason: This is the correct choice. The presence of erythema indicates you are allergic to the allergen, as it shows inflammation and irritation of the skin due to an immune response. Erythema is redness of the skin that can be accompanied by itching, swelling, or blisters.

Choice D Reason: The areas that did not turn red do not indicate low risk for skin cancer, but rather no reaction to the allergen. Skin cancer is a malignant growth of abnormal cells in the skin that can be caused by various factors, such as genetic mutations, exposure to carcinogens, or immunosuppression.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?

Correct Answer is A

Explanation

A client has a patch test performed with the following results. Which of the following is the best response the nurse will offer the client regarding the observations from the test?

Correct Answer is C

Explanation

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

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A nurse provides education to a client diagnosed with inflammatory bowel syndrome (IBS) about measures to treat diarrhea caused by acute flare-ups. Which statement by the client indicates a need for further teaching?

A client diagnosed with contact dermatitis is receiving education from the nurse. Which of the following therapies will the nurse recommend to the client?

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?

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