The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings are scored using the best motor response portion of the scale? Select all that apply
1. No response with eyes to commands.
2. Abnormal flexion to pain.
3. Pupil response sluggish.
4. Abnormal extension to pain.
5. Pupils fixed and dilated.
Correct Answer: 2, 4
The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. Abnormal flexion and extension to pain are findings from the motor response of the scale.
You might also like to view...
The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?
a. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy b. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
What is meconium-stained amniotic fluid associated with in the fetus?
a. Hypoxia c. Chromosomal dis-orders b. Prematurity d. Congenital anomalies
The patient has a peripheral infusion for the administration of antibiotics. Which action is most effective for the nurse to use to detect an intravenous (IV) therapy–related infection?
a. Use clean technique for dressing changes. b. Palpate the insertion site through the dressing. c. Change the IV tubing at 12-hour intervals. d. Routinely apply an antimicrobial to the IV site.
Antibiotics used as antineoplastic drugs are not selectively toxic to bacterial cells, so are different from the antibiotics used to treat infections
Indicate whether the statement is true or false.