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 ["B","C","E"]
Explanation
A) Alert and oriented: Being alert and oriented typically indicates adequate oxygenation, not hypoxia. Patients experiencing hypoxia are more likely to show signs of confusion or altered mental status rather than clarity.
B) Cyanosis: Cyanosis is a classic sign of hypoxia, presenting as a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is a significant indicator of inadequate oxygenation.
C) Anxiety and restlessness: These symptoms are common responses to hypoxia as the body attempts to compensate for insufficient oxygen. Patients may feel anxious or restless as they struggle to breathe or feel a sense of impending doom.
D) Oxygen saturation 96%: An oxygen saturation level of 96% is generally considered normal and indicates adequate oxygenation. Therefore, this finding does not suggest hypoxia.
E) Capillary refill 5 seconds: A prolonged capillary refill time can indicate poor perfusion and potential hypoxia. Inadequate blood flow can lead to reduced oxygen delivery to tissues, making this a relevant sign of hypoxia
Correct Answer is C
Explanation
A) Low self-esteem: While low self-esteem can develop as a result of limitations in physical abilities, it is not the most immediate concern in this scenario. Addressing the patient's functional capabilities and safety takes precedence.
B) His complaints of numbness in his hands: Numbness is a significant symptom of carpal tunnel syndrome, but the immediate priority is to ensure the patient can safely perform tasks. While it is important to address his symptoms, managing the risk associated with his condition is more critical.
C) Risk for injury: This is the most pressing concern for the patient. Given his difficulty holding tools, there is a heightened risk of accidents or injuries while working. Prioritizing safety measures is essential to prevent harm and ensure he can continue his work safely.
D) Persistent pain: While pain management is important, the focus should be on the immediate risk of injury related to the patient's inability to hold tools securely. Addressing safety concerns takes precedence over managing pain at this point.