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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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Regular insulin is the only insulin type that can be administered intravenously and is used in DKA treatment.

B. Lantus (glargine) is a long-acting insulin and is not used in acute situations.

C. Mixed insulins (intermediate and short-acting) are not appropriate for IV administration.

D. NPH is an intermediate-acting insulin and is not suitable for IV use.

A. Infuse the transfusion at a rate of 200 mL/hr. B. Check the patient's vital signs every hour during the transfusion. C. Leave the patient 5 minutes after beginning the transfusion. D. Flush the blood tubing with dextrose 5% in water.

Correct Answer is B

Explanation

A. Infuse the transfusion at a rate of 200 mL/hr. – Incorrect. The initial infusion should be slow (e.g., 75-100 mL/hr) to monitor for reactions.

B. Check the patient's vital signs every hour during the transfusion. – Correct Answer. Frequent monitoring is necessary to detect adverse reactions, such as fever or hypotension.

C. Leave the patient 5 minutes after beginning the transfusion. – Incorrect. The nurse should remain with the patient for the first 15 minutes, as most transfusion reactions occur early.

D. Flush the blood tubing with dextrose 5% in water. – Incorrect. Only normal saline should be used to flush blood tubing, as dextrose can cause hemolysis.

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When assessing a patient with a brain injury- using the Glasgow Coma Scale (GCS), the nurse gathers information regarding which of the following parameters?

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