The nurse is caring for a client with a neurological deficit. In assessing the client, the nurse will utilize the standard Glasgow Coma Scale. What will the nurse be assessing on this patient? Select all that apply.

Thought process.

Verbal response.

Motor response.

Eye response.

Cognitive ability.

Answer and Explanation

Correct Answer : B,C,D

The Glasgow Coma Scale (GCS) is a tool used to assess a patient's level of consciousness following a traumatic brain injury. It is based on three categories: eye-opening, verbal response, and motor response. The tool scores a patient from 3 to 15, with 15 being the best possible score. A score of 8 or less indicates a severe brain injury. The tool does not assess thought process or cognitive ability.

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Correct Answer is D

Explanation

sigmoid. A double-barrel colostomy involves surgically creating two separate stomas from the colon, with the proximal stoma discharging stool and the distal stoma discharging mucus. This type of colostomy is typically performed in the sigmoid colon, which is the S-shaped segment of the large intestine located just before the rectum.

Choice A, ascending, is not the correct answer because an ascending colostomy is created in the ascending colon, which is located on the right side of the abdomen.

Choice B, descending, is not the correct answer because a descending colostomy is created in the descending colon, which is located on the left side of the abdomen.

Choice C, transverse, is not the correct answer because a transverse colostomy is created in the transverse colon, which is located across the upper abdomen.

A. There will be blood and mucus initially exiting the stoma. B. The stoma will shrink a bit over a period of weeks. C. The stool will be of normal consistency and color. D. The stoma should be beefy red. E. Drainage will begin approximately 24-48 hours following surgery.

Correct Answer is ["A","B","D","E"]

Explanation

Pre-operative education is successful when the client states that there will be blood and mucus initially exiting the stoma, the stoma will shrink a bit over a period of weeks, the stoma should be beefy red, and drainage will begin approximately 24-48 hours following surgery. These statements indicate that the client has a good understanding of what to expect after surgery.

Option C, The stool will be of normal consistency and color, is not a correct answer as the stool from an ostomy is different from normal stool consistency and color.

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The nurse is caring for a client with a neurological deficit. In assessing the client, the nurse will utilize the standard Glasgow Coma Scale. What will the nurse be assessing on this patient? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for surgery and observes on the operative permit that the client will be having a double-barrel colostomy. What portion of the large intestine is the nurse aware that this is performed?

Correct Answer is D

Explanation

The nurse is providing patient education for a client who is going to have an ostomy created due to chronic Crohn's disease. The nurse has decided that pre- operative education is successful when the client states:. (select all that apply).

Correct Answer is ["A","B","D","E"]

Explanation

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