Author Question: The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The ... (Read 27 times)

asan beg · **on:** Jun 28, 2018

The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record?

a. 8 c. 13
b. 11 d. 15

Question 2

Which clinical manifestations would suggest hydrocephalus in a neonate?

a. Bulging fontanel and dilated scalp veins
b. Closed fontanel and high-pitched cry
c. Constant low-pitched cry and restlessness
d. Depressed fontanel and decreased blood pressure

Jane · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient's level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15.

Answer to Question 2

ANS: A
Bulging fontanel, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.