Glasgow Coma Scale Assessment
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Questions and Answers

What is the primary risk associated with administering enemas to older adults and pregnant women?

  • Increased risk of hyperkalemia
  • Development of colorectal cancer
  • Electrolyte imbalance and intestinal mucosa damage (correct)
  • Infection at the administration site

    • What makes normal saline enema the safest choice for infants and children?

  • It is isotonic and equal to the osmotic gradient (correct)
  • It has a high volume which encourages bowel movement
  • It has a medicinal effect on the intestinal lining
  • It draws excess fluid into the colon

    • Which type of enema should not be used for infants or dehydrated patients?

  • Medicated enema
  • Oil retention enema
  • Low-volume / hypertonic enema (correct)
  • Normal saline enema

    • In which position should a patient typically be placed for a cleansing enema?

    <p>Left side in Sims position with right leg flexed</p> Signup and view all the answers

    What is the recommended length of time a patient should retain a medicated enema for optimal effect?

    <p>1 to 2 hours</p> Signup and view all the answers

    What is the characteristic appearance of sanguineous exudate?

    <p>Bright red and fresh</p> Signup and view all the answers

    What type of exudate is indicative of infection in a wound?

    <p>Purulent</p> Signup and view all the answers

    When cleansing a clean surgical wound, how should the process be conducted?

    <p>With gentle friction from the incision to the surrounding skin</p> Signup and view all the answers

    What is the recommended pressure for irrigating a deep wound?

    <p>5 to 8 psi</p> Signup and view all the answers

    Which solution is NOT recommended for wound cleansing?

    <p>Distilled water</p> Signup and view all the answers

    What is the appropriate technique for irrigation of a wound?

    <p>Applying continuous pressure with a piston syringe</p> Signup and view all the answers

    How should sutures and staples be managed during wound care?

    <p>They should be removed when deemed necessary by a provider</p> Signup and view all the answers

    What outcomes indicate the effectiveness of administering antimicrobials in wound care?

    <p>Decreased white blood cell count and increased comfort</p> Signup and view all the answers

    What is the highest value on the Glasgow Coma Scale indicating full consciousness?

    <p>15</p> Signup and view all the answers

    What does the Romberg Test assess?

    <p>Balance</p> Signup and view all the answers

    Which sensory function test involves asking a client to identify an object placed in their hand?

    <p>Stereognosis</p> Signup and view all the answers

    What is the primary technique used in the Heimlich maneuver?

    <p>Inward and upward thrusts to the abdomen</p> Signup and view all the answers

    Which of the following describes bronchial breathing sounds?

    <p>Loud, hollow sound, high pitch</p> Signup and view all the answers

    What sign indicates early manifestations of hypoxia?

    <p>Restlessness and tachycardia</p> Signup and view all the answers

    Which condition could cause a pleural friction rub sound?

    <p>Pulmonary embolism</p> Signup and view all the answers

    What should be observed during the coordination assessment of motor function?

    <p>Client extending arms and touching their nose</p> Signup and view all the answers

    Where can cyanosis be assessed in darker skin tones?

    <p>Soles and palms</p> Signup and view all the answers

    What indicates bradypnea as a manifestation of hypoxia?

    <p>Decreased respiratory rate</p> Signup and view all the answers

    What does the pulse oximeter measure?

    <p>Oxygen saturation</p> Signup and view all the answers

    Which abdominal injury is a risk when performing the Heimlich maneuver?

    <p>Bruising of the stomach</p> Signup and view all the answers

    What sound is produced by air moving through thick mucus fluid?

    <p>Rhonchi</p> Signup and view all the answers

    In which breathing pattern does exhaling last longer than inhaling?

    <p>Bronchial</p> Signup and view all the answers

    What characterizes dehiscence in a wound?

    <p>Partial or total separation of a sutured wound</p> Signup and view all the answers

    What action should be taken immediately if a patient experiences evisceration?

    <p>Cover the wound with a sterile saline soaked towel</p> Signup and view all the answers

    During which stage of wound healing does scar strengthening occur?

    <p>Maturation or Remodeling Stage</p> Signup and view all the answers

    What is the primary characteristic of healing by primary intention?

    <p>Little or no tissue loss with edges approximated</p> Signup and view all the answers

    Which of the following is a risk factor for falls in older adults?

    <p>Altered cognition, such as dementia</p> Signup and view all the answers

    What is a key preventive strategy for falls among patients?

    <p>Educate clients on using the call light</p> Signup and view all the answers

    What type of gait involves swinging both legs past the crutches?

    <p>Swing-through gait</p> Signup and view all the answers

    What does the inflammatory stage of wound healing typically last?

    <p>3 to 6 days</p> Signup and view all the answers

    What is the major concern during the fall risk assessment for elderly patients?

    <p>Identifying and documenting patterns of falls</p> Signup and view all the answers

    What is a common outcome of healing by secondary intention?

    <p>Increased risk of infection and scarring</p> Signup and view all the answers

    What is the required positioning of the patient experiencing evisceration?

    <p>Supine with hips and knees bent</p> Signup and view all the answers

    Which of the following best describes tertiary intention healing?

    <p>Closure occurs when free of infection and edema</p> Signup and view all the answers

    What emotional state should be maintained for a patient at risk of shock?

    <p>Calmness</p> Signup and view all the answers

    What does the presence of heaves indicate in a patient?

    <p>Possible heart failure</p> Signup and view all the answers

    Which of the following heart sounds indicates the closure of the aortic and pulmonic valves?

    <p>S2</p> Signup and view all the answers

    Where is the apical pulse most accurately located?

    <p>Mid left clavicular line in the 4th or 5th intercostal space</p> Signup and view all the answers

    What is an indication of S3 heart sound?

    <p>Heart filling too fast</p> Signup and view all the answers

    What characterizes a stage 2 pressure injury?

    <p>Partial thickness skin loss with exposed dermis</p> Signup and view all the answers

    What should be used during a straight catheter insertion for a patient with a latex allergy?

    <p>Silicone or Teflon catheter</p> Signup and view all the answers

    Which dressing is most appropriate for maintaining a moist healing environment for a stage 2 pressure injury?

    <p>Hydrocolloid dressing</p> Signup and view all the answers

    What is a common characteristic of skin in stage 1 pressure injuries?

    <p>Non-blanchable erythema of intact skin</p> Signup and view all the answers

    What type of sound does a thrill resemble when felt at the heart?

    <p>Vibration like a purring kitten</p> Signup and view all the answers

    Which type of wound dressing is utilized for mechanical debridement?

    <p>Damp to damp dressing</p> Signup and view all the answers

    Which finding indicates potential right-sided heart failure?

    <p>Distended right jugular vein</p> Signup and view all the answers

    What does the Braden scale measure?

    <p>Risk of skin breakdown</p> Signup and view all the answers

    What type of drainage is characterized by clear and watery fluid, often seen in the early healing process?

    <p>Serous drainage</p> Signup and view all the answers

    Study Notes

    Glasgow Coma Scale

    • Utilized for baseline and ongoing assessments of consciousness.
    • Evaluates eye, verbal, and motor responses.
    • Scale ranges from 3 (no response) to 15 (full consciousness).

    Motor Function Assessment

    • Coordination: Client extends arms, alternating touch to nose; expected response: smooth movements.
    • Gait: Assessed without client’s awareness; expected: smooth and coordinated walking.
    • Balance:
      • Romberg Test: Stand with feet together, arms at sides, eyes closed for at least 5 seconds.
      • Heel-to-Toe Walk: Walking in a straight line without losing balance.
    • Muscle Strength: Client pushes or pulls against resistance; expected: equal or stronger on dominant side.

    Sensory Functions (Eyes Closed)

    • Pain Sensation: Alternating sharp/dull objects; client reports sensations.
    • Temperature: Identify warm/cold tubes.
    • Light Touch: Cotton ball touches skin; client indicates contact.
    • Vibration: Tuning fork; client reports sensation timing and location.
    • Position: Reposition limbs; client identifies orientation (up/down).
    • Discrimination:
      • Two-point discrimination: Measures minimal distance felt as two separate points.
      • Stereognosis: Identify familiar objects by touch.
      • Graphesthesia: Identify traced numbers on palm.

    Aspiration Risk

    • Assessment and precautions to prevent aspiration during care.

    Heimlich Maneuver

    • First-aid technique for conscious choking.
    • Sharp upward thrusts below ribcage, 5 times; adjust for pregnant individuals by maneuvering above the sternum.
    • Risks include potential injuries, bruising, or fractures.

    Diaphragmatic Breathing

    • Common in males and children; noticeable abdominal movement during deep breaths.

    Breathing Sounds

    • Expected:
      • Bronchial: High-pitched, hollow sounds; exhalation longer than inhalation.
      • Bronchovesicular: Medium-pitched; best heard between shoulders.
      • Vesicular: Low and soft; inhalation longer than exhalation.
    • Unexpected/Adventitious:
      • Crackles: Bubbling sounds indicating fluid in the lungs; suggest pulmonary issues.
      • Wheezes: High-pitched sounds from narrowed airways; associated with asthma or COPD.
      • Rhonchi: Deep, snoring sound; indicates thick mucus; can usually be cleared by coughing.
      • Pleural Friction Rub: Dry sounds indicating irritation of pleura; associated with breathing difficulty.
      • Apylexis: Absence of breath sounds.

    Cyanosis Assessment

    • Light skin tones: bluish tint; darker tones: grayish skin in palms/soles; brown tones: yellowish.
    • Indications of hypoxia or impaired venous return; commonly assessed at nail beds, lips, and mucous membranes.

    Hypoxia Manifestations

    • Early Signs:
      • Increased respiratory rate, heart rate; restlessness, anxiety.
      • Pale skin, elevated blood pressure, use of accessory muscles.
    • Late Signs:
      • Stupor, cyanosis, low respiratory rate, bradycardia, hypotension.

    Oxygen Saturation

    • Pulse Oximeter: Non-invasive device measures oxygen levels at various body sites.

    Indwelling Urinary Catheter Assessment and Care

    • Size/type for insertion varies by patient demographics; allergies necessitate specific materials.
    • Routine care should include cleansing and monitoring for patency and kinks.

    Wound Healing and Pressure Injury Classification

    • Stage 1: Non-blanchable erythema; discomfort.
    • Stage 2: Partial thickness loss; might resemble blister.
    • Stage 3: Full thickness skin loss; may expose subcutaneous fat.
    • Stage 4: Extensive tissue loss; muscles and bones may be visible.
    • Unstageable: Escar obscures true depth; may indicate serious risk factors.

    Wound Dressing Types

    • Woven Gauze: Absorbs exudate; used for moderate to heavy drainage.
    • Non-adherent Dressings: Prevent pain on removal; designed to avoid sticking.
    • Hydrocolloid: Forms a seal, maintains moisture; stays for several days.
    • Hydrogel: Provides moisture for dry wounds; soothing.
    • Alginates: Highly absorbent; ideal for draining wounds.

    Care of Wound Infection

    • Clean wounds from least to most contaminated; use isotonic solutions for cleansing.

    • For irrigation, maintain pressure and use appropriate tools; monitor for infection signs.### Wound Complications: Dehiscence and Evisceration

    • Dehiscence: Partial or total separation of a sutured wound, typically affecting underlying skin layers.

    • Presents with visible wound edge separation and serous drainage.

    • Patients may report a popping sensation and feeling as though the wound has given way.

    • Immediate actions: Notify healthcare provider, stay with the patient, cover the wound with a blanket or pillow, and apply pressure if coughing occurs.

    • Evisceration: Severe dehiscence where organs protrude through the wound.

    • Requires immediate coverage of the wound with a sterile saline-soaked towel or dressing to prevent bacterial contamination.

    • Keep essentials nearby to avoid unnecessary movement.

    • Patient Positioning: Supine position with hips and knees bent reduces tension on the wound.

    • Observation: Monitor for signs of shock such as pallor, clamminess, rapid heart rate, and hypotension. Maintain a calm environment and keep the patient NPO until surgery.

    Stages of Wound Healing

    • Inflammatory Stage: Lasts 3 to 6 days, focusing on controlling bleeding and delivering immune response elements.

    • Features vasoconstriction, fibrin accumulation, and macrophage activity for phagocytosis.

    • Prolonged inflammation can occur due to inadequate or excessive responses.

    • Proliferative Stage: Lasts from 3 to 24 days, characterized by tissue replacement and granulation.

    • Involves collagen formation, wound contraction, and resurfacing with new epithelial cells.

    • Maturation Stage: Begins around day 21, with scar strengthening and normalization of appearance.

    • The process may take over a year and depends on the wound's extent.

    Wound Healing Processes

    • Primary Intention: Minimal tissue loss, with edges approximated, healing rapidly and presenting low infection risk. Example includes closed surgical incisions.

    • Secondary Intention: Involves significant tissue loss with unapproximated edges, longer healing times, and a higher infection risk. Example includes pressure injuries.

    • Tertiary Intention: Characterized by deep, widely separated wounds that initially remain open for infection control. Closure occurs later, extending healing time.

    Fall Risk Assessment

    • Defined as an unintended descent to the ground, making it a leading cause of accidental injuries, especially among older adults.
    • Risk factors include unassisted toileting, altered cognition, mobility issues, and environmental hazards.

    Fall Prevention Strategies

    • Conduct fall-risk assessments at admission and regular intervals.

    • Educate clients on using call lights and demonstrate proper usage.

    • Ensure call lights are accessible, and offer timely bathroom assistance.

    • Maintain good room lighting and familiarization with the environment.

    • Ensure accessibility to assistive devices and safety elements like non-skid footwear.

    • Document any falls in incident reports to identify patterns and refine prevention strategies.

    Crutch Walking Techniques

    • 4 Point Gait: Alternates crutches and legs, providing stable support with three points on the ground.

    • 3 Point Gait: Both crutches move forward together while swinging the unaffected leg ahead.

    • 2 Point Gait: Moves one crutch with the opposite leg simultaneously, mimicking natural walking.

    • Swing Through Gait: Involves swinging legs past crutches, requiring upper body strength for balance.

    Other Mobility Considerations

    • Utilize gait belts and various mobility assistance devices for safe ambulation.

    Dosage Calculations

    • Understand oral, parenteral, and injectable dosage calculations for effective medication management.

    Tuberculin Test

    • The PPD test is used for tuberculin testing, assessing for allergies or sensitivities to medications.

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    NURS 112 Study Guide PDF

    Description

    Test your knowledge on the Glasgow Coma Scale and its application in assessing a client's level of consciousness. This quiz covers the scale's components, including eye, verbal, and motor responses, as well as understanding the scoring system from 3 to 15.

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