The nurse is assessing a client that experienced a head injury ...

[viki]

The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings are scored using the best motor response portion of the scale? Select all that apply.
 
  1. No response with eyes to commands.
  2. Abnormal flexion to pain.
  3. Pupil response sluggish.
  4. Abnormal extension to pain.
  5. Pupils fixed and dilated.

Question 2

The nurse is interviewing a client with suspected Lyme disease. Which question is the priority in this situation?
 
  1. When was your last seizure?
  2. Have you been hiking or camping lately?
  3. What has your temperature been running?
  4. Do you have an appetite?

[FergA]

Answer to Question 1

Correct Answer: 2, 4
The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. Abnormal flexion and extension to pain are findings from the motor response of the scale.

Answer to Question 2

Correct Answer: 2
Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. If not treated Lyme disease may result in neurological disorders. There is not, however, any indication that the client has long-term Lyme disease or neurological changes. During the initial period after becoming infected the client may experience flu-like illnesses but there is no indication that this is the primary concern for the client. While appetite changes may result during an infection this is not the priority for the nurse's questions.

[viki]

Thank you

[FergA]

No problemo