A student nurse is asked by the preceptor to identify which of the assigned clients is at the highest risk for stroke. Which of the clients below, when selected by the student nurse, indicate an understanding of the highest risk factor for stroke?

A client who has been treated for diabetes for 10 years.

A client who has been treated for blood pressure for 4 years.

An AfricanAmerican client

A client treated for atrial fibrillation with clopidogrel (Plavor)

Answer and Explanation

The Correct Answer is D

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Correct Answer is B

No explanation

A. The client opens his eyes when spoken to B. The client can follow simple motor commands C. The client is unconscious D. The client is unable to make vocal sound.

Correct Answer is A

Explanation

A. A GCS score of 3 for eye opening indicates that the client opens their eyes in response to speech. This accurately reflects the client's level of responsiveness.

B. A GCS score of 5 for motor response indicates that the client localizes pain or can follow simple motor commands. However, this does not fully encapsulate the most appropriate conclusion, given the specific GCS score for eye opening.

C. A total GCS score of 13 (3 for eye opening, 5 for verbal response, and 5 for motor response) suggests mild impairment, not unconsciousness. Unconsciousness is typically indicated by a GCS score of 8 or below.

D. A GCS score of 5 for verbal response indicates the client is oriented and can respond verbally, so they are capable of making vocal sounds.

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A student nurse is asked by the preceptor to identify which of the assigned clients is at the highest risk for stroke. Which of the clients below, when selected by the student nurse, indicate an understanding of the highest risk factor for stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?

Correct Answer is B

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?

Correct Answer is A

Explanation

A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.

A nurse caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?

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A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.

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