Ortho quiz

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

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. A score of 20 b. A score of 15 c. A score of 9 d. A score of 4

A score of 9

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 each shift. This assessment evaluates:

cranial nerves IX and X.

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

Refrain from eating or drinking for now.

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? a) Dysfunction of the spinal accessory nerve b) Dysfunction of the acoustic nerve c) Dysfunction of the vagus nerve d) Dysfunction of the facial nerve

dysfunction of the vagus nerve