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 D
Explanation
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B) Border regularity: Irregular borders can suggest malignancy; however, the presence of burning and bleeding is a more pressing sign that warrants immediate attention. While border irregularity is important to assess, it is not as concerning as changes in color or the presence of symptoms like bleeding.
C) Diameter less than 6 mm: A diameter less than 6 mm is generally considered a normal size for moles and is not indicative of malignancy on its own. In this case, the burning and bleeding of the mole are more significant findings that raise concern, regardless of its size.
D) Color variation: Color variation in a pigmented lesion is a significant danger sign, as it can indicate changes that may suggest malignancy, especially when combined with other concerning symptoms like burning and bleeding. Variability in color may indicate the presence of different cell types and is a key factor in assessing the risk of melanoma.
Correct Answer is ["A","C","D","E"]
Explanation
A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.
B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.
C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.
D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.
E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.