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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.

B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.

C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.

D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.

A. White Blood Cell decrease B. Platelets increase C. Hemoglobin increase D. PT and INR normalize

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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What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

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What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?