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ati predictor 3 bought to study 2

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A nurse is caring for a client with a closed head injury. When pressure is applied to the client's nail beds, the client's eyes open and adduction of the arms with flexion of the elbows and wrists is ... noted. The client also moans with stimulation. What is this client's Glasgow Coma Score? The GCS is calculated by using appropriate stimuli (a painful stimulus may be necessary such as pressure to the nail beds) and then assessing the client's response in three areas. Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. A nurse is caring for several clients prescribed heat/cold therapies. Which of the following clients are at risk of injury from these therapies? Select all that apply. .......................................................................................continued.......................................................................................................... [Show More]

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