A child with a motor response subscale of 5 from the Glasgow Coma ...

[mynx]

A child with a motor response subscale of 5 from the Glasgow Coma Scale indicates:
 
  1. Decorticate posturing.
   2. Probable pediatric brain injury.
   3. Total neurological unresponsiveness.
   4. Purposeful movement, able to localize pain.

Question 2

The nurse is doing an assessment on a 4-month-old infant. Which of the following assessment findings would the nurse consider abnormal?
 
  1. The posterior fontanel is open.
   2. The anterior fontanel is open and soft.
   3. The infant is able to roll only from abdomen to back.
   4. The infant has good head control when held upright

[Li Jun]

Answer to Question 1

2
Rationale:
1. Decorticate posturing is seen with a motor response of 3.
2. A Glasgow Coma Scale, motor response subscale score of 5 is strongly correlated with pediatric brain injury.
3. A score of 3 from the motor response subscale indicates total neurological unresponsiveness.
4. Purposeful movement and being able to localize pain is seen with a score of 5 in the motor response.

Answer to Question 2

1
Rationale:
1. The posterior fontanel closes between 2 and 3 months of age.
2. An open anterior fontanel, which is soft, is a normal finding at 4 months.
3. Rolling from abdomen to back is a skill the 4-month-old should be learning.
4. Good head control is expected at 4 months of age.

[mynx]

Thank you

[Li Jun]

No problemo