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) Subjective report: The most reliable indicator of pain is the patient's own description of their experience. Pain is inherently subjective, and individuals may perceive and express pain differently. Listening to the client's self-report provides valuable insight into their pain intensity, quality, and impact on daily life, which cannot be accurately assessed through objective measures alone.
B) Physical exam: While a physical exam can provide important information about potential sources of pain or related conditions, it may not accurately reflect the intensity or nature of the pain the patient is experiencing. Physical findings may vary widely among individuals with similar pain complaints, making this a less reliable indicator.
C) Results of a CAT scan: Imaging studies like CAT scans can identify structural issues, such as fractures or tumors, but they do not measure pain. Many patients with significant pain may have normal imaging results, while others with severe findings may report minimal discomfort, underscoring the limitations of relying solely on diagnostic tests.
D) The client's vital signs: Vital signs can indicate physiological responses to pain, such as increased heart rate or blood pressure, but they are not specific indicators of pain severity. Many factors can influence vital signs, including anxiety and other medical conditions, making them unreliable for assessing pain levels independently.
Correct Answer is ["A","C","D"]
Explanation
A) Include the student and family in a meeting to elicit her feelings about scoliosis and wearing a brace: This intervention is essential as it encourages open communication and allows the student to express her concerns and feelings about her condition and the brace. Involving the family ensures that they can provide support and understanding during this transition.
B) Suggest that the pediatrician prescribe an anti-anxiety agent for the student: While managing anxiety may be important, it is not the nurse's role to suggest medication without a thorough assessment and evaluation by a healthcare provider. This intervention may not be appropriate in the context of providing support for scoliosis.
C) Teach the student and family about clothing that will hide the brace: This intervention is practical and can help the student feel more comfortable and confident while wearing the brace. By discussing clothing options, the nurse can help alleviate some of the psychological stress associated with wearing a visible brace.
D) Provide contact information for a local scoliosis support group to the student and family: Connecting the family with a support group can provide valuable resources and emotional support. It allows them to engage with others who understand their experiences, which can be reassuring and help them navigate the challenges of scoliosis.