GI & Neuro Med Surg week 10 prep

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semicomatose state? A score of 20 A score of 15 A score of 9 A score of 4

A score of 9

Nonmechanical (functional, paralytic illeus) bowel obstruction

Absence of peristalsis due to diabetes, neurologic disorders or manipulation of the bowel during surgery

A patient suffered a stroke. The nurse implements an assessment plan to monitor for potential deterioration of the neurological status. Which manifestation does the nurse anticipate seeing first, if neurological deterioration occurs? Bradycardia Slurred speech Increased systolic blood pressure Alteration in level of consciousness (LOC)

Alteration in level of consciousness (LOC)

Mechanical bowel obstruction

An obstruction of the lumen of the intestine due to intussusception, tumors, stenosis, strictures, adhesions, or hernias

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. Best judgment Best eye opening Best verbal response Best motor response Best sensory response

Best eye opening Best verbal response Best motor response

The nurse has documented a patient diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as which of the following? Coma Minimally responsive Least responsive Most responsive

Coma

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: Cranial nerves I and II Cranial nerves III and V Cranial nerves VI and VIII Cranial nerves IX and X

Cranial nerves IX and X

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? Dysfunction of the spinal accessory nerve Dysfunction of the acoustic nerve Dysfunction of the facial nerve Dysfunction of the vagus nerve

Dysfunction of the vagus nerve

A patient who is in a coma is having a test that represents a record of the electrical activity generated in the brain. The nurse should understand that the patient is having which diagnostic test? Lumbar puncture (LP) Transcranial Doppler Cerebral angiography Electroencephalogram (EEG)

Electroencephalogram (EEG)

Diverticulitis Inflammation of a diverticulum resulting in abscess formation

Inflammation of a diverticulum resulting in abscess formation

Diverticulosis

Presence of several diverticula in the intestine

The nurse has completed evaluating the cranial nerves of a patient. The nurse documents impairment of the cranial nerves (CN IX and CN X). Based on these findings, the nurse will instruct the patient to complete which of the following? Refrain from eating or drinking for now. Have your husband bring in your glasses. While you are in the hospital, wear your hearing aids. When you walk, use your walker.

Refrain from eating or drinking for now.

A client has sustained a head injury to the occipital area. He cannot identify a familiar object by looking at it. The nurse knows that this deficit is which of the following? Astereognosis Positive Romberg Visual Agnosia Ataxia

Visual Agnosia

subarachnoid space

lies between the arachnoid and the pia mater.

what the ventricles of the brain do

manufacture and absorb cerebral spinal fluid.

pia mater

the delicate inner layer of the meninges.

dura mater

the tough outer layer of the meninges.