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 B
Explanation
A. Removal of the educating patient to carry an Epipen
While educating the patient about carrying an Epipen is essential in managing anaphylaxis, it is not the primary action in preventing anaphylactic shock before exposure to an allergen.
B. Assess and document for previous allergies and drug reactions prior to medication administration
Identifying and documenting allergies before administering medications or treatments helps prevent exposure to known allergens, reducing the risk of anaphylaxis.
C. Administer diphenhydramine and solumedrol IV at the first sign of allergic symptoms
These medications help in managing allergic reactions but do not prevent anaphylactic shock. Preventive measures focus on avoiding allergen exposure rather than treating symptoms after they occur.
D. Application of a red allergy bracelet on the patient’s upper extremity
This helps alert healthcare providers about allergies, but it does not prevent anaphylactic shock. It is a precautionary step rather than a primary prevention strategy.
Correct Answer is C
Explanation
A. Respiratory rate 24 and bloody drainage in the NG tube
While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.
B. Client is oriented to name and place but not the date
This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.
C. Blood pressure 40/48 and urine output of 24 mL/hour
This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.
D. Hypo-active bowel sounds and tachycardia
Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.
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