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 A
Explanation
A. Notify the physician and anticipate the need for endotracheal intubation
The client is showing progressive airway obstruction due to inhalation injury. The absence of wheezes indicates impending respiratory failure, requiring immediate airway management.
B. Place the client in semi-Fowler's position and administer an albuterol breathing treatment
Albuterol may help bronchospasm, but this client's issue is upper airway swelling, not bronchospasm. Intubation is the priority.
C. Encourage the client to cough, take deep breaths, and then auscultate again
The loss of wheezes suggests airway swelling has worsened, not that secretions are the issue. Immediate intervention is needed.
D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry
Guaifenesin and incentive spirometry help with secretion clearance, but they are not the priority in this emergent airway situation.
Correct Answer is D
Explanation
A. Continue to monitor the client as a paralytic ileus is possible
Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.
B. Administer the PRN stool softener to the client
A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.
C. Obtain an order to insert a nasogastric tube set to low suction
An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.
D. Report the assessment findings to the surgeon
Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.
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