Practice Question
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Answer Choices:
Correct Answer:
The client can follow simple motor commands.
Rationale:
🧠 A GCS motor score of 5 means the client localizes or follows simple motor commands (e.g., moving limbs when told).
🧠 A total GCS score helps determine consciousness level, but motor response is one of the best single indicators.
🧠 The other options (unconscious, no vocal sound) would suggest much lower scores.
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This question is from RN ATI Custom Nurs Exam which contains 48 questions.
More Questions from This Exam
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Answer Choices:
A. Uneven cast drying
B. Infection
C. Pressure from the cast
D. Poor circulation
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Answer Choices:
A. Tophi
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A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?
Answer Choices:
A. Place a trochanter roll against the thigh.
B. Place a sandbag to the lateral calf.
C. Place a wedge pillow between the legs.
D. Place a footboard on the bed.
A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the clients right leg?
Answer Choices:
A. Internal rotation
B. Adduction
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A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
Answer Choices:
A. Check the client for injuries.
B. Obtain a prescription tor medication to sedate the client.
C. Call the family and ask them to make arrangements for someone to sit with the client.
D. Assist the client back into bed and apply restraints.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 4