The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What will the nurse do next?
Re-assess in 15 minutes
Ask the patient to open eyes on command
Document the findings
Notify the physician
The Correct Answer is C
A) Re-assess in 15 minutes: While regular assessments are important in a neurological evaluation, if the Glasgow Coma Scale (GCS) score is 15, indicating the patient is fully alert and oriented, there may not be an immediate need to re-assess so soon unless the patient's condition changes.
B) Ask the patient to open eyes on command: If the GCS score is already determined to be 15, this indicates that the patient is responsive and capable of opening their eyes spontaneously. Asking the patient to open their eyes is unnecessary in this context since the score already reflects full responsiveness.
C) Document the findings: Documenting the GCS score of 15 is crucial as it establishes a baseline for the patient’s neurological status. This documentation is essential for ongoing assessments and monitoring, providing a record of the patient’s condition at this moment.
D) Notify the physician: Notifying the physician is not required for a GCS score of 15, as this score indicates a normal level of consciousness. Communication with the physician would be warranted only if there were changes in the patient's condition or a lower GCS score observed.
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Correct Answer is A
Explanation
A) Lordosis: This term specifically refers to an exaggerated inward curvature of the spine, particularly in the cervical or lumbar regions. When the nurse observes an exaggerated cervical curve, lordosis is the correct term to use for documentation, indicating a deviation from the normal spinal alignment.
B) Scoliosis: This condition is characterized by an abnormal lateral curvature of the spine. It does not apply to the observation of an exaggerated cervical curve and would not be appropriate for this finding.
C) Kyphosis: This term denotes an excessive outward curvature of the thoracic spine, often leading to a hunchback appearance. Since the assessment focuses on the cervical region, kyphosis would not accurately describe an exaggerated cervical curve.
D) Normal curve: This term refers to the expected, healthy curvature of the spine. Documenting an exaggerated curve as "normal" would be misleading and does not accurately reflect the observed condition. The nurse should document the finding as lordosis to convey the specific abnormality noted.
Correct Answer is C
Explanation
A) Talking in a loud voice: While this may indicate some level of distress or confusion, it does not necessarily signal a specific neurological deficit. Clients may raise their voice for various reasons unrelated to neurological issues.
B) Grimacing with movement: This could suggest discomfort or pain but is not an explicit indicator of neurological impairment. Grimacing can occur for many reasons, including musculoskeletal issues or emotional responses, and does not specifically necessitate a focused neurological assessment.
C) Asymmetry of the client's smile: This finding is significant and raises concerns about potential neurological issues, such as a stroke or Bell's palsy. Facial asymmetry may indicate weakness or dysfunction in the cranial nerves responsible for facial movement, warranting a more thorough neurological examination to assess for underlying causes.
D) Inability to follow directions: While this may point to confusion or cognitive impairment, it is a more general indicator and could result from various factors, including anxiety or lack of understanding. It does not specifically highlight a localized neurological deficit as clearly as facial asymmetry does.