Author Question: An emergency department nurse receives a report that an incoming client has a Glascow Coma Scale ... (Read 32 times)

Sufayan.ah · **on:** Jul 22, 2018

An emergency department nurse receives a report that an incoming client has a Glascow Coma Scale (GCS) score of 8. The nurse prepares to implement which of the following?

1. Treat the client's pain
2. Assess airway, breathing, and circulation
3. Get a complete history from the client
4. Triage with the other emergency department clients

Question 2

Which patient has stress incontinence?

a. The patient states her bladder empties, but she doesn't know when it will happen because she has no sensation of fullness or urge to void.
b. The patient states she has a strong urge to void, but usually cannot make it to the toilet in time.
c. The obese patient complains of dribbling urine when she sneezes or bends over.
d. The patient states she urinates small amounts frequently, but examination shows bladder distention.

scottmt · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2. Assess airway, breathing, and circulation

Rationale:
The GCS (Glascow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness, and a score of 8 or less is usually indicative of comathe lowest possible score is 3. A comatose client receives high priority, and the nurse will utilize the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and triage with other departments are done only after the airway is clear and the client is breathing.

Answer to Question 2

C
Stress urinary incontinence is the uncontrolled loss of urine caused by physical exertion in the absence of a detrusor muscle contraction. Urge urinary incontinence can be unpredictable. Functional incontinence can occur when unable to reach the toilet in time. Urgency can lead to urinary retention.