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 C

Explanation

A. Urine output of less than 0.5 mL/kg

Norepinephrine is a vasopressor used to improve perfusion. A urine output of less than 0.5 mL/kg suggests ongoing hypoperfusion and inadequate organ perfusion, which is an undesirable outcome.

B. Improved mental status, decreased lactate level

These are positive indicators of improved perfusion and oxygen delivery, but they are not the primary target for norepinephrine therapy.

C. A mean arterial pressure (MAP) of 65

A MAP of at least 65 mmHg is the target for vasopressor therapy, as it ensures adequate perfusion of vital organs.

D. A pain level of 4 or less on a scale of 0-10

While pain management is important, norepinephrine’s primary role is not pain control but rather maintaining adequate perfusion.

A. Elevate the extremity and apply an ice pack to the injured area B. Contact poison control to determine the best neutralizing agent C. Apply a sterile dressing, wrapping the fingers separately D. Irrigate the affected area with room temperature water

Correct Answer is D

Explanation

A. Elevate the extremity and apply an ice pack to the injured area

Elevating the extremity can help reduce swelling, but applying ice is not recommended for chemical burns as it can cause further tissue damage.

B. Contact poison control to determine the best neutralizing agent

While contacting poison control is important, it should not be the immediate first action in an emergency setting.

C. Apply a sterile dressing, wrapping the fingers separately

This is important for protecting the wound, but it is not the immediate first action needed for chemical burns.

D. Irrigate the affected area with room temperature water

Immediate irrigation with room temperature water helps to remove the chemical from the skin and dilute its effect, which is the first critical step in managing a chemical burn.

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

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Naxlex Comprehensive Predictor Exams

A client with hypovolemic shock who did not respond to fluid resuscitation is started on norepinephrine. What is the desired outcome?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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