The Nurse Is Assessing the Level of Consciousness of a Client

question 40

Multiple Choice

The nurse is assessing the level of consciousness of a client who suffered a head injury.She uses the Glasgow Coma Scale and determines that the client's score is 15.Which responses did the nurse assess in this client? Select all that apply.

• A) Spontaneous eye opening
• B) Tachypnea, bradycardia, and hypotension
• C) Unequal pupil size
• D) Orientation to person, place, and time
• E) Motor response to pain localized

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Definitions:

Negative Withdrawal

refers to the act or feeling of psychological or emotional detachment, often as a coping mechanism in response to stress or trauma.

Tantrums

Emotional outbursts that are typically characterized by yelling, crying, and aggressive or resistant behavior, commonly seen in young children.

Rough-And-Tumble Play

An activity that includes physical exertions such as sprinting, pursuing, and mock combat, crucial for both social interaction and physical growth.

Physical Activity

Any bodily movement produced by skeletal muscles that requires energy expenditure, including activities undertaken while working, playing, carrying out household chores, traveling, and engaging in recreational pursuits.