Answer to Question 1
1, 2, 3
Rationale: Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The three categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of total assessment of the neurological status of a client but is not part of this particular scale. Many standardized neurological assessment forms include the pupillary response on the same page, but separate from the Glasgow Coma Scale data.
Answer to Question 2
2
Rationale: The nurse should become aware of the client's strengths and encourage the client to work at the optimal level of functioning. In When the physician arrives on the unit, I will let him or her know that you have a question. the nurse is helping the client develop resources. The nurse does not act for clients unless absolutely necessary and then only as a step toward helping clients act on their own. Consistently encouraging clients to use their own resources helps mini-mize clients' feelings of helplessness and dependency and also validates their potential for change.
Assessment of CN I
Abnormal physical assessment findings
Eqiupment and supplies for physical assessment
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