An intensive care unit (ICU) nurse is preparing to assess a client who experienced multiple trauma injuries and is on assisted ventilation for level of conscious (LOC)
The nurse recognizes that the FOUR Score Consciousness Scale is the most appropriate evaluation tool because it: 1. Does not include verbal responses.
2. Requires minimal interaction on the part of the client.
3. Is designed especially for intensive care unit clients.
4. Focuses primarily on assessment of cognitive ability.
Does not include verbal responses.
Rationale: Verbal response is not a component of the FOUR Score Consciousness Scale, making it fully applicable for intubated clients. The tool does require client participation in evaluating its four focus components: eye, motor, brainstem, and respiration. Cognitive ability is not assessed by this tool, nor is it designed for any specific type of client.
You might also like to view...
In selecting a blood pressure cuff of appropriate size for a client, the nurse should remember that the bladder inside the cuff should encircle what percentage of the adult client's arm for accurate measurement?
a. 50 c. 70 b. 60 d. 80
To reach magnet status the nursing service in a hospital must attain competency in the following areas
a. Professionalism b. Use of critical thinking skills c. Business skills and principles d. Leadership e. Communication and relationship management f. Knowledge of the health care environment g. Implement an acuity-based staffing system
The nurse is preparing to educate a group of athletes about their dietary intake
Which of the following concepts regarding dietary intake of vitamins and minerals would be important to teach an ice hockey player but would not necessarily be as important to teach to a field hockey player? 1. Importance of vitamin A 2. Importance of vitamin C 3. Importance of vitamin E 4. Importance of vitamin D
A female client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which statement by the nurse best conveys empathy?
A) "I know you are feeling very depressed right now. I felt the same way when I decided to leave my husband. But I can tell you from personal experience, you are doing the right thing." B) "I can understand that you are feeling depressed right now. It was a very difficult decision to make. I'll sit here with you for awhile." C) "I am very sorry you are going through this difficult time. I wish things could be better for you." D) "It is a sad thing to have to break up a marriage. It's unfortunate that it didn't work out for you."