As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale (GCS). What responses will the nurse assess to determine the patient's GCS score? Select all that apply.
A) Best sensory response
B) Best judgment
C) Best eye opening
D) Best verbal response
E) Best motor response
Question 2
A college football player is brought to the emergency room by paramedics after a blunt trauma injury received during game. There is a high suspicion that the patient has sustained an injury to his kidneys from being tackled from behind.
The emergency room nurse caring for the patient reviews the initial orders written by the health care provider and notes that an order has been written to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important because:
A) Hematuria is the most common manifestation of renal trauma, and blood losses may be microscopic, so laboratory analysis is essential.
B) Intake and output calculations are essential, and the laboratory will calculate the precise urine output produced by this patient.
C) A creatinine clearance study may be ordered at a later time, and the laboratory will hold all urine until it is determined if the test will be necessary.
D) There is great concern about electrolyte imbalances, and the laboratory will monitor the urine for sodium concentrations.
When using an interpreter, the nurse should pose questions directly to the patient, not the interpre
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