The nurse is performing a Glasgow Coma Scale (GCS) on a ...

[asan beg]

The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record?
 
  a. 8 c. 13
  b. 11 d. 15

Question 2

Which clinical manifestations would suggest hydrocephalus in a neonate?
 
  a. Bulging fontanel and dilated scalp veins
  b. Closed fontanel and high-pitched cry
  c. Constant low-pitched cry and restlessness
  d. Depressed fontanel and decreased blood pressure

[Jane]

Answer to Question 1

ANS: D
The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient's level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15.

Answer to Question 2

ANS: A
Bulging fontanel, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.

[asan beg]

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