What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?
Vocalization, strength, and pupillary response and accommodation
Eye opening. verbal response, and motor response
Pupillary reaction, eye opening, and motor response
Motor response. sensory response, and level of consciousness
The Correct Answer is B
A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.
B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.
C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.
D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.
B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.
C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.
D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.
Correct Answer is B
Explanation
A. White Blood Cell decrease
Platelet transfusions do not affect WBC levels. WBCs may change in response to infection or inflammation, but this is not an indicator of successful platelet transfusion.
B. Platelets increase
The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.
C. Hemoglobin increase
Hemoglobin levels increase after red blood cell (RBC) transfusions, not platelet transfusions.
D. PT and INR normalize
PT/INR measures clotting function, which is affected by clotting factors, not platelets. Platelet transfusions do not directly correct prolonged PT/INR.
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