Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Verbal respond

Motor respond

Pupillary responds

Gag Reflex

Eye Opening

Answer and Explanation

Correct Answer : A,B

A.   The verbal response is one of the three components of the Glasgow Coma Scale. It assesses the patient's ability to speak and respond appropriately to questions, indicating their level of consciousness. Responses are scored based on clarity, coherence, and relevance.
B.   Motor response is another component of the Glasgow Coma Scale. It evaluates the patient’s ability to move in response to stimuli, including purposeful movements, localizing pain, or abnormal posturing. The motor response helps gauge the patient’s level of consciousness and neurological function.
C.   Pupillary response refers to how the pupils react to light and changes in size. While important in neurological assessments, it is not one of the three components of the Glasgow Coma Scale. Pupillary response is assessed separately from the GCS but provides additional information about brain function and potential injury.
D.   The gag reflex is a protective mechanism to prevent choking and is assessed by stimulating the back of the throat. It is not included in the Glasgow Coma Scale. The GCS focuses on eye opening, verbal response, and motor response rather than reflexes.
E.   Eye opening is the third component of the Glasgow Coma Scale. It assesses the patient’s ability to open their eyes spontaneously or in response to stimuli. This component helps determine the level of consciousness and alertness.

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Correct Answer is B

Explanation

A. Bursitis is the inflammation of the bursa, a small fluid-filled sac that reduces friction between bones and soft tissues. It typically causes localized pain and tenderness in the area of the bursa, often in the shoulders, elbows, or hips.

B. Meningitis is an infection or inflammation of the protective membranes covering the brain and spinal cord (the meninges). It often presents with symptoms such as fever, headache, neck stiffness, and photophobia. The neck stiffness, particularly difficulty flexing the head forward (nuchal rigidity), is a classic sign.
C. Spondylitis refers to inflammation of the spine. It can present with chronic back pain and stiffness but is typically associated with long-term symptoms rather than acute systemic symptoms like fever and chills. Conditions such as ankylosing spondylitis can cause chronic back pain and stiffness but are less likely to present with acute fever and headache.
D. Arthritis is inflammation of the joints and can cause pain, swelling, and stiffness in the affected joints. While arthritis can affect the neck (cervical spine arthritis), it typically does not present with systemic symptoms such as fever and chills unless there is an associated infection or inflammatory process.

A. Hallucination B. Perseveration C. Fugue state D. Illusion

Correct Answer is A

Explanation

A. A hallucination is a sensory experience that occurs without any external stimulus. It involves perceiving things that are not present in the environment, such as hearing voices or seeing things that are not there. The young man hearing his deceased sister talking to him in his head is an example of an auditory hallucination, which is a common symptom in schizophrenia.
B. Perseveration is the repetitive and persistent repetition of a particular response, such as a word or action, despite the absence of a stimulus or the problem being resolved. It is not related to abnormal sensory perceptions but rather to repetitive behaviors or speech. The young man's experience of hearing voices does not fit this description.
C. A fugue state is a type of dissociative disorder where a person suddenly and unexpectedly travels away from home or customary work locations and cannot recall their past. It often involves amnesia for personal history. The scenario described does not involve such travel or amnesia but rather auditory experiences, making this term irrelevant.
D. An illusion is a misperception of an actual external stimulus. It involves incorrectly interpreting a real sensory input, such as mistaking a shadow for a person. Since the young man is not misinterpreting a real external stimulus but rather hearing something that is not present at all, an illusion does not accurately describe his experience.

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Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is A

Explanation

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

The nurse places a coin in the patient's hand, the patient is with eyes closed. The ability to identify an object by feeling it is defined as:

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?