The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of
7
12
10
15
The Correct Answer is D
A. A score of 7 would indicate a much lower level of consciousness and require urgent intervention.
B. A score of 12 would indicate some level of impairment, with the patient not fully alert or responsive.
C. A score of 10 would indicate some level of impairment, with the patient not fully alert or responsive.
D. A score of 15 on the Glasgow Coma Scale indicates full consciousness and normal neurological function. It is the highest possible score, reflecting a patient who is awake, aware, and able to follow commands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.
C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.
Correct Answer is B
Explanation
A. Dehydration causes a drop in circulating blood volume, which can lead to lower blood pressure, not muffled sounds.
B. When a person is dehydrated, there is less fluid in the bloodstream, which typically causes a decrease in blood pressure.
C. Blood pressure is likely to decrease in dehydration due to reduced circulating volume, rather than remain unchanged.
D. Dehydration will not increase blood pressure; it typically causes a compensatory decrease in blood pressure.
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