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The nurse enters the client’s room and notes the client looking spontaneously around the room. The client is able to state their name, date of birth, and allergies when prompted for that information.  The nurse asks for permission to assess the client’s vitals and the client lifts the right arm for the nurse to apply the blood pressure cuff. The client’s blood pressure is 114/72 mm Hg, heart rate is 81, respiratory rate is 16, and temperature is 37.9°C. The client rates their pain a 2/10 and describes it as a dull ache behind the left eye.  What is the client’s Glasgow Coma Scale score? Write the number in the blank below. 

When caring for a client with a brain tumor, the nurse notes extension of the arms and legs and plantar flexion. How does the nurse document these findings?

Which painful stimuli should the nurse avoid when calculating the Glasgow Coma Scale score of a client who sustained severe facial fractures?

The nurse is caring for a client following a hemorrhagic cerebral vascular accident. Which risk factor should the nurse help the client develop a plan to change?

What cranial nerve is the LPN/LVN assessing when touching a tongue depressor to the back of the pharynx to elicit the gag reflex?

A CNA is extinguishing a fire that has broken out in the workplace.  Which is the first step the CNA should take?

Which of the following best defines steatorrhea?

While providing care for an older patient, the CNA notices that the patient has had only small, frequent, watery stool for several days  Which intervention doe the CNA anticipate the nurse will perform as a result of these findings?

1 kilogram of weight gain is equal to how many mL of fluid retention?

Which of the following statements are true regarding a colostomy stoma