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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Free Nursing Study Resources

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

Explanation

A. The groin area is prone to skin breakdown due to friction, moisture, and pressure, especially in immobile patients.
B. The coccyx (tailbone) is a high-risk area for pressure ulcers due to constant pressure when sitting, particularly in bedridden patients.
C. The heels are vulnerable to pressure ulcers because they are under constant pressure when lying down or when standing for prolonged periods.
D. While the scapula may be at risk in certain conditions (e.g., if the patient is immobile and lying on their back), it is generally not as high-risk as other areas like the coccyx or heels.
E. This area is at risk due to moisture, friction, and pressure from the breast tissue, especially in obese or immobile patients.

A. Apply an eye patch to the client's right eye. B. Provide range-of-motion exercises to the client's neck and shoulders. C. Avoid the use of warm water to wash the client's face. D. Place suction equipment at the client's bedside.

Correct Answer is D

Explanation

A. While an eye patch may be needed for other conditions (e.g., facial paralysis), it is not a primary concern in this case.
B. Range-of-motion exercises are not related to cranial nerve IX and X impairment.
C. Avoiding warm water to wash the face is not specifically relevant to cranial nerve impairment.
D. Suction equipment should be available for clients with cranial nerve impairment, especially if they have swallowing difficulties or potential for aspiration.

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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?

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Naxlex Comprehensive Predictor Exams

When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

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

Explanation

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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