A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.

A Glasgow Coma Scale (GCS) score of 7 or less is generally
interpreted as
a) coma.
The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s
response to stimuli. A score of 7 or less is generally interpreted as
coma.
b) a need for emergency attention.
A GCS score of 10 or less indicates a need for emergency attention.
c) least responsive.
A GCS score of 3 is interpreted as least responsive.
d) most responsive.
A GCS score of 15 is interpreted as most responsive.
by

1 Answer

Answer :

a) coma.
The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s
response to stimuli. A score of 7 or less is generally interpreted as
coma.
by

Related questions

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

Of the following areas for assessing the patient profile, which should be addressed after the others? a) Body image The patient is often less anxious when the interview progresses from information that is less personal to information that is more personal. b) Education Educational level is relatively impersonal and readily revealed by the patient. c) Occupation Occupation is relatively impersonal and readily revealed by the patient. d) Environment Housing, religion, and language are relatively impersonal and readily revealed by the patient.

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Last Answer : a) Body image The patient is often less anxious when the interview progresses from information that is less personal to information that is more personal.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

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Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

How many Geospatial Expeditionary Planning Tool (GeoExPT) or NIPRnet computer stations are located in the Ground Control Station (GCS)?

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The thermal and electric pulp tests will, A. Give an accurate indications of the pulp status B. The patient’s response will be either pain or no pain C. The patient can differentiate between cold or hot stimuli

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When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma. b) normal. A class 1 Pap smear is interpreted as normal. c) probably normal. A class 2 Pap smear is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

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Which of the following refers to a management tool for organizing personnel, facilities, equipment, and communication for any emergency situation? a) The Incident Command System The Incident Command System (ICS) is a management tool for organizing personnel, facilities, equipment and communication for any emergency situation. The federal government mandates that the ICS be used during emergencies. Under this structure, one person is designated as incident commander. This person must be continuously informed of all activities and informed about any deviation from the established plan. While the ICS is primarily a field structure and process, aspects of it are used at the level of an individual hospital’s emergency response plan as well.

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Of the following stimuli, which is known to trigger an episode of autonomic hyperreflexia in the patient who has suffered a spinal cord injury? a) Applying a blanket over the patient An object on the skin or skin pressure may precipitate an autonomic hyperreflexic episode.

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The process of assessing the probability and consequences of identified risks to the project objectives, assigning a risk score to each risk, and creating a list of prioritized risks describes which of the following processes? A. Quantitative Risk Analysis B. Risk Identification C. Qualitative Risk Analysis D. Risk Management Planning

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The first step in decontamination is a. Removal of the patient’s clothing and jewelry and then rinsing the patient with water. To be effective, decontamination must include a minimum of two steps. The first step is removal of the patient’s clothing and jewelry and then rinsing the patient with water. The second step consists of a thorough soap and water wash and rinse.

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Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement, airway management, and standard nursing care support during the time that the patient has meningitis symptoms. a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

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The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Description : The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression ... contraindicated when injury is suspected, and examination, while indicated, does not provide treatment.

Last Answer : a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

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Description : Bone density testing in patients with post-polio syndrome has demonstrated a) low bone mass and osteoporosis. Bone density testing in patients with post-polio syndrome has demonstrated low bone ... density testing in patients with post-polio syndrome has demonstrated low bone mass and osteoporosis.

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Which of the following statements reflect nursing interventions of a patient with post-polio syndrome? a) Providing care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient. No specific medical or surgical treatment is available for this syndrome and therefore nursing plays a pivotal role in the team approach to assisting patients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Nursing interventions are aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient.

Description : Which of the following statements reflect nursing interventions of a patient with post-polio syndrome? a) Providing care aimed at slowing the loss of strength and maintaining the physical, ... and cold are most appropriate because these patients tend to have strong reactions to medications.

Last Answer : a) Providing care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient. No specific medical or surgical treatment is available for ... loss of strength and maintaining the physical, psychological and social well being of the patient.

What percentage of patients who survived the polio epidemic of the 1950s are now estimated to have developed post-polio syndrome? a) 60-80% Patients who survived the polio epidemic of the 1950s, many now elderly, are developing new symptoms of weakness, fatigue and musculoskeletal pain. It is estimated that between 60% and 80% of the 640,000 polio survivors are experiencing the phenomenon known as post-polio syndrome.

Description : What percentage of patients who survived the polio epidemic of the 1950s are now estimated to have developed post-polio syndrome? a) 60-80% Patients who survived the polio epidemic of the 1950s ... 80% of patients who survived the polio epidemic of the 1950s are now experiencing post-polio syndrome.

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The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS) is closely monitored for a) leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

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Three medications referred to as the ‘ABC drugs’ are currently the main pharmacological therapy for multiple sclerosis. Which of the following statements reflects information to be included in patient teaching? a) Flu-like symptoms can be controlled with nonsteroidal antiinflammatory drugs (NSAIDs) and usually resolve after a few months of therapy. Seventy-five percent of patients taking one of the interferons experience flu-like symptoms that can be controlled with NSAIDS and usually resolve after a few months of therapy.

Description : Three medications referred to as the ABC drugs' are currently the main pharmacological therapy for multiple sclerosis. Which of the following statements reflects information to be included in patient ... on an empty stomach. Glatiramer acetate is administed by intramuscular injection once a week.

Last Answer : a) Flu-like symptoms can be controlled with nonsteroidal antiinflammatory drugs (NSAIDs) and usually resolve after a few months of therapy. Seventy-five percent of patients taking one of the ... symptoms that can be controlled with NSAIDS and usually resolve after a few months of therapy.

Which of the following diseases is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain? a) Parkinson’s disease In some patients, Parkinson’s disease can be controlled; however, it cannot be cured.

Description : Which of the following diseases is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain? a) ... of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.

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When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Description : When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's ... rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Last Answer : a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following? a) Decreased or absent deep tendon reflexes Structural and motor changes related to aging that may be assessed in geriatric patients include decreased or absent deep tendon reflexes.

Description : Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following? a) Decreased or absent deep ... and movement times Strength and agility are diminished and reaction and movement times are decreased.

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The percentage of patients over the age of 70 admitted to the hospital with delirium is about a) 25%. About 25% of patients over the age of 70 admitted to the hospital have delirium. The cause is often reversible and treatable (as in drug toxicity, vitamin B12 deficiency or thyroid disease) or chronic and irreversible. Depression may produce impairment of attention and memory.

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Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following? a) Bed rest Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo, and patients with acute vertigo may be medicated with meclizine for 1-2 weeks.

Description : Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following? a) Bed rest Bed rest is recommended for patients with acute symptoms. ... -Hallpike procedure. The Dix-Hallpike test is an assessment test used to evaluate for BPPV.

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Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the patient’s attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

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Last Answer : a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience ... orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.

Description : Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid ... fluid requirements. d) Hypoglycemia Hypoglycemia is not associated with increased fluid requirements.

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Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Which of the following terms refers to a graft derived from one part of a patient’s body and used on another part of that same patient’s body? a) Autograft Autografts of full-thickness and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury.

Description : Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body? a) Autograft Autografts of full-thickness and pedicle ... A heterograft is a graft obtained from an animal of a species other than that of the recipient.

Last Answer : a) Autograft Autografts of full-thickness and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury.

Which of the following reflect the pathophysiology of cutaneous signs of HIV disease? a) Immune function deterioration Cutaneous signs may be the first manifestations of HIV, appearing in more than 90 per cent of HIV infected patients as the immune function deteriorates. Common complaints include pruritis, folliculitis, and chronic actinic dermatitis.

Description : Which of the following reflect the pathophysiology of cutaneous signs of HIV disease? a) Immune function deterioration Cutaneous signs may be the first manifestations of HIV, appearing in more ... Decrease in normal skin flora Cutaneous signs of HIV disease appear as immune function deteriorates.

Last Answer : a) Immune function deterioration Cutaneous signs may be the first manifestations of HIV, appearing in more than 90 per cent of HIV infected patients as the immune function deteriorates. Common complaints include pruritis, folliculitis, and chronic actinic dermatitis.

The nurse reading the physician’s report of an elderly patient’s physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

Description : The nurse reading the physician's report of an elderly patient's physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is ... red moles. Cherry angioma is the term that is used to describe a bright red mole.

Last Answer : a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

Osteoarthritis is known as a disease that a) is the most common and frequently disabling of joint disorders. The functional impact of osteoarthritis on quality of life, especially for elderly patients, is often ignored.

Description : Osteoarthritis is known as a disease that a) is the most common and frequently disabling of joint disorders. The functional impact of osteoarthritis on quality of life, especially for elderly patients, ... causes the described problem and is usually diagnosed in the second or third decade of life.

Last Answer : a) is the most common and frequently disabling of joint disorders. The functional impact of osteoarthritis on quality of life, especially for elderly patients, is often ignored.

When the patient’s eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Description : Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the ... term home IV therapy (eg, Port A Cath, Mediport, Hickman Port, P.A.S. Port).

Last Answer : a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints. b) achalasia. Achalasia presents as difficulty in swallowing both liquids and solids. c) gastroesophageal reflux. Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty in or pain upon swallowing. d) hiatal hernia. Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Description : Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour ... as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Last Answer : a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints.

When gastric analysis testing reveals excess secretion of gastric acid, which of the following diagnoses is supported? a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid.

Description : When gastric analysis testing reveals excess secretion of gastric acid, which of the following diagnoses is supported? a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess ... anemia Patients with pernicious anemia secrete no acid under basal conditions or after stimulation.

Last Answer : a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Description : When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not ... Paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Last Answer : a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

When the valve used in valve replacement surgery is made from the patient’s own heart valve, which of the following terms is used? a) Autograft An example of autograft is found when the surgeon excises the pulmonic valve and uses it for an aortic valve replacement. b) Allograft Allograft refers to replacement using human tissue and is a synonym for homograft. c) Homograft Homograft refers to replacement using human tissue and is a synonym for allograft. d) Xenograft Xenograft refers to replacement of tissue from animal tissue.

Description : When the valve used in valve replacement surgery is made from the patient's own heart valve, which of the following terms is used? a) Autograft An example of autograft is found when the ... and is a synonym for allograft. d) Xenograft Xenograft refers to replacement of tissue from animal tissue.

Last Answer : a) Autograft An example of autograft is found when the surgeon excises the pulmonic valve and uses it for an aortic valve replacement.