Author Question: The nurse is going to assess a patient with the Glasgow Coma Scale. This scale includes all of the ... (Read 101 times)

elizabeth18 · **on:** Jul 22, 2018

The nurse is going to assess a patient with the Glasgow Coma Scale. This scale includes all of the following areas, EXCEPT

a. cognition c. verbal response
b. eye opening d. motor response

Question 2

A nurse is assessing a teenage client and suspects that the client has been sexually abused. Which question will prompt a response that will aid the nurse in making an accurate assessment?

1. Has anyone touched you in a way that made you feel uneasy or uncomfortable?
2. How is your relationship with your parents and older siblings?
3. Do you have any bruises anywhere on your body?
4. Do you like to dress in provocative outfits?

Joy Chen · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
The Glasgow Coma Scale assesses three areas of behavior: eye opening, verbal response, and motor response. Cognitive level is not assessed with this scale.

Answer to Question 2

1. Has anyone touched you in a way that made you feel uneasy or uncomfortable?

Rationale:
It is important to ask directly whether the client has been made uneasy or uncomfortable, as this would indicate that further assessment is necessary. The other answers express personal biases about the cause of abuse and the identity of the abuser, or are vague in that they can fit scenarios that may have nothing to do with abuse.