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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B. Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C. Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D. Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.

A. become muffled. B. decrease. C. remain the same. D. Increase

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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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

Correct Answer is A

Explanation

If dehydration occurs, the blood pressure will

Correct Answer is B

Explanation

The nurse covers a newborn baby's head with a cap. because the head:

A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/84 mm Hg places him in which of the following categories?

When a fever begins to come down. the patient is in a state of

The nurse taking a blood pressure should:

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of

A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a: