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 C

Explanation

Peritonitis. The assessment findings of an absence of bowel sounds and a very rigid abdomen in a client with severe abdominal pain, nausea, and vomiting are indicative of peritonitis. Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. The inflammation can occur due to an infection or other causes, and it can cause abdominal pain, nausea, vomiting, and a rigid abdomen. An absence of bowel sounds is also a characteristic finding of peritonitis.

A is not the correct answer because ulcerative colitis is a chronic inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum.

B is not the correct answer because appendicitis is inflammation of the appendix, which can cause right lower quadrant abdominal pain, nausea, vomiting, and fever.

D is not the correct answer because diverticulitis is inflammation of one or more diverticula, which are small pouches that can form in the colon. It can cause left lower quadrant abdominal pain, fever, diarrhea, or constipation.

A. The client will maintain a low-residue diet. B. Sips of fluid may be increased if tolerated. C. An enema will be used to clear the bowel. D. The stools may be white or clay-colored.

Correct Answer is B

Explanation

Sips of fluid may be increased if tolerated. After a barium enema, the client may be allowed to increase fluid intake to help eliminate the barium and prevent constipation.

Option A: The client will maintain a low-residue diet is not a correct answer as it is not necessary after a barium enema.

Option C: An enema will be used to clear the bowel is not a correct answer as the barium enema is itself a type of enema used to visualize the colon.

Option D: The stools may be white or clay-colored is not a correct answer as it is a potential side effect of barium use, not an instruction to the client.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

Correct Answer is C

Explanation

Which nursing instruction is correct to provide the client following a barium enema?

Correct Answer is B

Explanation

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