The student nurse is assisting with an assessment of a client's ...

[madam-professor]

The student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale.
 
  The student understands that which of the following categories of client functioning are included in this assessment? Select all that apply. 1. Eye opening
  2. Best verbal response
  3. Best motor response
  4. Pupil size and reaction
  5. Reflex response

Question 2

The nurse is developing a care plan that will include goals that will help the client achieve an optimal level of functioning and appropriate resource utilization.
 
  When the nurse enters the cli-ent's room, the client asks the nurse, Could you ask the physician to let me have a pass for the weekend? The nursing response that assists the client in achieving these goals is: 1. When your doctor comes in, I will ask for a pass for the weekend.
  2. When the physician arrives on the unit, I will let him or her know that you have a question.
  3. I will call the doctor and find out if you can have a pass so that you can make your arrangements.
  4. You can't have a pass for the weekend. You are not ready, and I'm sure that your doctor will say no.

[asware1]

Answer to Question 1

1, 2, 3

Rationale: Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The three categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of total assessment of the neurological status of a client but is not part of this particular scale. Many standardized neurological assessment forms include the pupillary response on the same page, but separate from the Glasgow Coma Scale data.

Answer to Question 2

2

Rationale: The nurse should become aware of the client's strengths and encourage the client to work at the optimal level of functioning. In When the physician arrives on the unit, I will let him or her know that you have a question. the nurse is helping the client develop resources. The nurse does not act for clients unless absolutely necessary and then only as a step toward helping clients act on their own. Consistently encouraging clients to use their own resources helps mini-mize clients' feelings of helplessness and dependency and also validates their potential for change.

[madam-professor]

Gracias!

[ashely1112]

Excellent