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 C

Explanation

A. History of recent exposure to poison ivy: This is unrelated to tinea pedis (athlete's foot), which is caused by a fungal infection.
B. Papular, erythematous patches on the scalp: This is more indicative of a condition like tinea capitis, not tinea pedis.
C. Scaling and redness between the client's toes: This is the classic presentation of tinea pedis, a fungal infection commonly found in the spaces between the toes.
D. Report of a recent prescription for an antiseizure medication: This is not a typical finding for tinea pedis and may be unrelated.

A. Check the function of cranial nerve V. B. Observe for the presence of Kernig's sign. C. Inspect for the presence of clubbing. D. Perform a Romberg's test.

Correct Answer is D

Explanation

A. Cranial nerve V (trigeminal) is not directly related to ataxia or balance. It is more involved in sensory perception of the face and motor function for chewing.
B. Kernig's sign is a test for meningitis, not ataxia or balance issues. It involves flexing the hips and knees to check for resistance or pain that may suggest meningeal irritation.
C. Clubbing is related to chronic oxygenation issues or respiratory/cardiovascular conditions, but it is not a direct assessment of ataxia or balance.
D. A Romberg's test is used to assess balance and proprioception. By having the client stand with feet together and eyes closed, the nurse can assess the client's ability to maintain balance and identify any unsteadiness or ataxia that may impair safe ambulation.

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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 in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Correct Answer is D

Explanation

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