The student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale
The student understands that which of the following categories of client functioning are included in this assessment? Select all that apply. 1. Eye opening
2. Best verbal response
3. Best motor response
4. Pupil size and reaction
5. Reflex response
1, 2, 3
Rationale: Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The three categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of total assessment of the neurological status of a client but is not part of this particular scale. Many standardized neurological assessment forms include the pupillary response on the same page, but separate from the Glasgow Coma Scale data.
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A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect?
A) Increases the amount of mucus production B) Destabilizes hemoglobin C) Shrinks the alveoli in the lungs D) Collapses the alveoli in the lungs
Which job responsibilities indicate that a nurse has supervisory capacity? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. The nurse makes clinical judgments about client care. 2. The nurse assigns a nurse assistant to care for a team of clients. 3. The nurse discusses client care with the supervising physician. 4. The nurse hires staff to manage units. 5. The nurse retains responsibility for the actions of nurses assigned to provide client care.
The nurse is explaining hepatitis to a high school health occupations class. The students all volunteer examples of how hepatitis is transmitted. Which student statement indicates the need further education?
A) "Body piercing or tattoo with infected equipment." B) "Contaminated food or fluids." C) "Alcoholism or drug overdose." D) "Bite of an infected mosquito or tick."
A client accompanied her boyfriend to the emergency department after the two had been in a
motorcycle accident. The boyfriend was badly hurt, but the client had only minor cuts and bruises. The client appears confused and has trouble focusing on what the nurse is saying. She reports nausea and dizziness, has tachycardia, and is hyperventilating as the nurse interviews her. She tells the nurse that she feels as though something awful is going to happen. The nurse should assess the client's level of anxiety as a. mild. b. moderate. c. severe. d. panic.