When assessing a patient with a brain injury- using the Glasgow Coma Scale (GCS), the nurse gathers information regarding which of the following parameters?
Level of consciousness
Reflex activity
Sensory involvement
Cognitive ability
The Correct Answer is A
A. Correct. The GCS assesses level of consciousness based on eye-opening, verbal response, and motor response.
B. Incorrect. Reflex activity is assessed separately using neurological reflex tests.
C. Incorrect. Sensory involvement is evaluated through different neurological exams, not the GCS.
D. Incorrect. Cognitive ability assessment requires specialized tests, such as the Mini-Mental State Examination (MMSE).
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Related Questions
Correct Answer is D
Explanation
A. Placing a pillow under the patient's head is inappropriate because it may obstruct the airway and does not prevent aspiration.
B. Loosening restrictive clothing can be helpful but is not the priority over airway protection.
C. Clearing the area of hazards is important to prevent injury, but airway protection takes precedence.
D. Positioning the patient in a side-lying position is the priority to maintain airway patency and reduce the risk of aspiration in case of vomiting.
Correct Answer is A
Explanation
A. Administer antibiotics when available. – Correct Answer. Bacterial meningitis is a medical emergency. The priority is to start IV antibiotics as soon as possible to prevent complications such as sepsis, increased ICP, and neurological damage.
B. Reduce environmental stimuli. – Incorrect. While reducing stimuli helps with photophobia and headache, it is not the priority over immediate antibiotic therapy.
C. Document intake and output. – Incorrect. Monitoring fluid balance is important, but it does not directly treat the infection.
D. Maintain seizure precautions. – Incorrect. Seizure precautions are necessary, but rapid antibiotic administration takes precedence.
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