The nurse is performing a neurologic assessment of a 41-year-old patient the patient is able to open eyes to pain, uses inappropriate words, and has flexion withdrawal from pain. What is their GCS score?

Answer and Explanation

The Correct Answer is A

The Glasgow Coma Scale (GCS) measures three aspects: Eye response, verbal response, and motor response.

Eye response: Opens eyes to pain (score 2).

Verbal response: Uses inappropriate words (score 3). Motor response: Flexion withdrawal from pain (score 4). Total GCS = 2 (eyes) + 3 (verbal) + 4 (motor) = 9.

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Correct Answer is A

Explanation

A. Pinnae of the ears are one of the most reliable sites for detecting cyanosis in individuals with dark skin, as the color changes are more apparent in the mucous membranes and earlobes.
B. Dorsal surface of the hand may not reliably show cyanosis in darker skin tones, and it’s often less
visible.
C. Dorsal surface of the foot is not typically where cyanosis would be identified.
D. Conjunctivae can be used for detection in individuals with darker skin, but it is typically harder to visualize than the pinna.

A. “As a nurse, I am required by law to report suspected child abuse.” B. "I reported the incident to my supervisor who decided to contact the authorities." C. "The provider will be coming to explain the situation." D. ”I am unable to discuss this, but I can contact my supervisor to speak with you."

Correct Answer is A

Explanation

A. The nurse is legally obligated to report suspected child abuse according to mandatory reporting laws. This response directly addresses the nurse’s legal responsibility without providing unnecessary details to the parents.
B. Reporting the incident to a supervisor does not fully address the nurse's legal obligation, which is to report the abuse to the authorities.
C. It is inappropriate to defer to the provider in this case, as the nurse holds the legal responsibility to report the suspicion.
D. The nurse should not avoid the discussion but instead provide a clear, legal explanation for their actions.

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The nurse is performing a neurologic assessment of a 41-year-old patient the patient is able to open eyes to pain, uses inappropriate words, and has flexion withdrawal from pain. What is their GCS score?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is A

Explanation

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is caring for a client. Exhibits

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