A child has sustained a traumatic brain injury, and is being monitored in the pediatric intensive care unit. The nurse is using the Glasgow Coma Scale to assess the child. Which assessments will be included? Select all that apply
1. Eye opening
2. Verbal response
3. Motor response
4. Head circumference
5. Pulse oximetry
1; 2; 3
Rationale:
1. The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurologic functioning. Head circumference and pulse oximetry are not included on the scale.
2. The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurologic functioning. Head circumference and pulse oximetry are not included on the scale.
3. The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurologic functioning.
4. Head circumference is not included on the Glasgow Coma Scale.
5. Pulse oximetry is not included on the Glasgow Coma Scale.
You might also like to view...
The nurse admits a client with a newly diagnosed abdominal aortic aneurysm scheduled for surgery tomorrow. When examining the client, the nurse takes special care not to:
1. Increase the client's anxiety. 2. Palpate the abdomen. 3. Elevate the feet and legs. 4. Administer beta blockers.
A patient comes to the community health clinic with complaints of changes in urination. Which of the following would lead the community health nurse to suspect that the patient has benign prostatic hypertrophy (BPH)?
A) Nighttime frequency B) Dysuria C) Hematuria D) Flank pain
When caring for a hospitalized adolescent, a nurse should do which of the following? Select all that apply
1. Talk down to the adolescent. 2. Treat the adolescent with respect. 3. Encourage peers to visit. 4. Insist that a parent be present during examinations and procedures. 5. Assume that the adolescent has no knowledge of his or her illness.
For a client who had a transsphenoidal resection of a pituitary tumor, the nurse plans to
a. assess the "mustache" dressing for drainage. b. do minimal mouth care for the first 2 days. c. encourage the use of straws when drinking. d. provide heated mist and humidified oxygen.