Nokea
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.
You may also like to solve these questions
Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
- A. The Food Guide Pyramid
- B. The South Beach Diet
- C. The Step One Diet
- D. The Dash diet
Correct Answer: D
Rationale: Step 1: The DASH diet is specifically designed to help lower blood pressure, making it the most appropriate choice for clients with hypertension.
Step 2: The DASH diet emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy, all of which are beneficial for managing hypertension.
Step 3: The diet also limits sodium intake, which is crucial for controlling blood pressure.
Step 4: The other options (A, B, and C) do not have the same evidence-based focus on hypertension management and may not be as effective in lowering blood pressure.
What is the primary purpose of the outcome identification and planning step of the nursing process?
- A. To collect and analyze data to establish a database
- B. To interpret and analyze data so as to identify health problems
- C. To write appropriate client-centered nursing diagnoses
- D. To design a plan of care for and with the client
Correct Answer: D
Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
- A. Yearly after age 40
- B. After the birth of the first child and every 2 years thereafter
- C. After the first menstrual period and annually thereafter
- D. Every 3 years between ages 20 and 40 and annually thereafter
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. The American Cancer Society recommends yearly mammograms after age 40 for early breast cancer detection.
2. Mammograms are most effective for women aged 40 and older in detecting breast cancer.
3. Regular mammograms can help detect breast cancer at an early stage, improving treatment outcomes.
Summary of why other choices are incorrect:
B: Mammograms should start at age 40, not after the birth of the first child.
C: Mammograms are not recommended after the first menstrual period; they should start at age 40.
D: Mammograms should be done annually after age 40, not every 3 years between ages 20 and 40.
Why is heart biopsy performed throughout a clients lifetime after heart transplantation?
- A. To detect rejection
- B. To check the heart functionality
- C. To check rate of the heartbeat
- D. To check for heart tumor CARING FOR CLIENTS WITH HYPERTENSION
Correct Answer: A
Rationale: The correct answer is A: To detect rejection. After heart transplantation, heart biopsy is performed to monitor for rejection, a common complication. Tissue samples are examined for signs of rejection, such as inflammation. This is crucial for timely intervention to prevent rejection-related complications.
Other choices are incorrect:
B: Heart functionality is typically assessed through imaging tests like echocardiograms, not biopsy.
C: Heart rate monitoring can be done through non-invasive methods like electrocardiograms, not biopsy.
D: Checking for heart tumors is not a primary purpose of heart biopsy post-transplantation.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.