Question

The Glascow Coma Scale is a widely used, reliable tool to assess level of consciousness. a. Verbal response, eye opening and pupillary function b. Truncal stability, obeying commands and pupillary function c. Pupil response, muscle strength and obeying commands d. Eye opening, verbal response and obeying commands 1. The nurse knows the three indicators it measures are: 2. The nurse is assessing her patient with a head injury. Which finding should be communicated to the physician immediately? Pupils equal but sluggish b. Pupils equal and constricted Pupils fixed and dilated d. Pupils dilated with brisk response a. C. 3. The nurse is caring for a patient involved in a motor vehicle accident with a severe head injury. The nurse knows to access for Cushing's triad symbolizing an increase in intracranial pressure (ICP). Which of the following apply) are seen with Cushing's triad? (Select all that Narrowing pulse pressure b. Widening pulse pressure Bradycardia d. Tachycardia Irregular respirations a. c. e. 4. A patient enters the emergency department via ambulance with a severe head injury. During the care provided, the patient is observed with arms adducted and arms, wrists and fingers flexed. The nurse recognizes this as: Decorticate posturing b. A side effect from a medication a. c. Decerebrate posturing d. Stress response 5. The nurse is caring for a patient with Multiple Sclerosis. The patient asks what causes Multiple Sclerosis. Which of the following is the correct response by the nurse? Sensory loss of the limbs b. Demyelination of nerve fibers c. Slowness of the execution of movement d. Decrease in acetylcholine a. 6, A patie assisted diagnosis

Answer 1

Answer: (D) Eye opening, verbal response and obeying commands.

(The Glascow coma scale indicators it measures are the eye opening response, best verbal response as well as best motor response)

Answer: (C) Pupils fixed and dilated.

(During the head Injury the pupil get also injured and sometimes damaged)

Answer: Bradycardia, widening pulse pressure.

Answer: Stress response.