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 D

Explanation

Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.

Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.

Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.

Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.

A. A 40 year old female who drives a motorcycle B. A pregnant female who has high blood pressure C. A 18 year old male who smokes and has a family history of brain cancer D. A 65 year old male client who golfs 3 times a week and drives a golf cart

Correct Answer is A

Explanation

Choice A Reason: This is the correct choice because driving a motorcycle is a high-risk activity that can expose the client to head trauma, especially if they do not wear a helmet. Traumatic brain injury (TBI) is a condition where the brain is damaged by an external force, such as a collision, fall, or assault.

Choice B Reason: This is incorrect because having high blood pressure is not a direct risk factor for traumatic brain injury. High blood pressure can increase the risk of stroke, which is a condition where the brain is damaged by an internal cause, such as a blood clot or hemorrhage.

Choice C Reason: This is incorrect because smoking and having a family history of brain cancer are not risk factors for traumatic brain injury. Smoking and genetic factors can increase the risk of developing brain tumors, which are abnormal growths of cells in the brain.

Choice D Reason: This is incorrect because golfing and driving a golf cart are low-risk activities that do not pose a significant threat to the client's head. Golfing and driving a golf cart may cause minor injuries, such as sprains, strains, or bruises, but not traumatic brain injury.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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