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 C

Explanation

A. Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B. Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C. Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D. Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.

A. dialysis shunt. B. 2-year-old hand amputation. C. previous mastectomy. D. patent IV line.

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

Explanation

A. A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B. A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C. A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D. A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.

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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

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Naxlex Comprehensive Predictor Exams

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

Correct Answer is C

Explanation

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

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

Explanation

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

A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is

A 16-year-old patient sustained a head injury while playing soccer. When performing a neurologic check, the nurse looks at each pupil to determine

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?

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

The nurse would record a pulse as bradycardic if the rate were:

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