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
Explanation
Choice A Reason: This is correct because eating frequent small meals can help the client with IBS to avoid overloading the digestive system and triggering diarrhea. The nurse should advise the client to eat slowly and chew well, and avoid foods that are spicy, fatty, or gas-producing.
Choice B Reason: This is incorrect because increasing the intake of leafy greens and other sources of dietary fiber can worsen diarrhea by increasing stool bulk and motility. The nurse should advise the client to limit or avoid high-fiber foods, such as whole grains, fruits, vegetables, nuts, and seeds, during acute flare-ups of IBS. The client can gradually reintroduce fiber when the symptoms subside.
Choice C Reason: This is correct because increasing fluids can help the client with IBS to prevent dehydration and electrolyte imbalance caused by diarrhea. The nurse should advise the client to drink at least 8 glasses of water per day and avoid caffeinated, alcoholic, or carbonated beverages that can irritate the bowel or cause gas.
Choice D Reason: This is correct because taking prescribed medications on schedule can help the client with IBS to regulate bowel patterns and reduce diarrhea. The nurse should instruct the client on how to use medications, such as antidiarrheals, antispasmodics, or probiotics, as ordered by the provider. The nurse should also monitor the client for any adverse effects or interactions of the medications.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because it is necessary to remove contact lenses before administering medications. Contact lenses can absorb or interfere with the absorption of eye drops and cause irritation or infection. The nurse should instruct the client to remove contact lenses before applying eye drops and wait at least 15 minutes before reinserting them.
Choice B reason: This is incorrect because administering the medications by touching the tip of the dropper to the sclera of the eye can cause contamination or injury. The sclera is the white part of the eye that covers most of the eyeball. The nurse should instruct the client to avoid touching the tip of the dropper to any part of the eye or eyelid and hold it about 1 cm above the lower eyelid.
Choice C reason: This is correct because administering the medications 5 min apart can prevent dilution or washout of one medication by another. Timolol and pilocarpine are two different types of eye drops that are used to treat open-angle glaucoma, which is a condition that causes increased pressure inside the eye and damage to the optic nerve. Timolol is a beta-blocker that reduces the production of fluid in the eye, and pilocarpine is a cholinergic agent that increases the drainage of fluid from the eye. The nurse should instruct the client to apply one drop of each medication in the affected eye(s) and wait at least 5 minutes between each medication.
Choice D reason: This is incorrect because holding pressure on the conjunctival sac for 2 min following the application of eye drops can reduce systemic absorption and side effects of eye drops. The conjunctival sac is the space between the lower eyelid and the eyeball. The nurse should instruct the client to gently close their eyes after applying eye drops and press their index finger against the inner corner of their eye for 2 minutes. This can block the tear duct that drains fluid from the eye to the nose and prevent it from entering the bloodstream.
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