Williams & Hopper Chapter 47 & 48 Questions with Answers
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Williams & Hopper
Williams & Hopper Chapter 47 & 48 Questions with Answers
A patient has a Glasgow Coma Scale score of 5. What does this score suggest to the nurse?
1. Asleep
2. Lethargic
3. Comatose
4. Hyperreactive - Answer-3
A Glasgow Coma Scale score of less than 7 indicates a comatose patient. The total ...
Williams & Hopper Chapter 47 & 48
Questions with Answers
A patient has a Glasgow Coma Scale score of 5. What does this score suggest to the
nurse?
1. Asleep
2. Lethargic
3. Comatose
4. Hyperreactive - Answer-3
A Glasgow Coma Scale score of less than 7 indicates a comatose patient. The total
possible score of Glasgow Coma Scale ranges from 3 to 15. A score of 15 indicates a
fully alert patient; a score of 13 or 14, a mild head injury; 9 to 12, a moderate injury; and
any score of 8 or below a severe head injury. The score does not measure if a patient is
asleep or lethargic. Hyperreactive is a term used to describe reflex responses.
While collecting subjective data as part of a neurological assessment, the nurse asks
the patient to subtract 7 from 100 and then 7 from that answer, and so on. Which
neurological function is the nurse assessing?
1. Memory
2. Perception
3. Thought content
4. Intellectual function - Answer-4
The "serial 7s" question is used to assess intellectual function. Thought content may be
assessed by asking the patient a question such as "What would you do if you smelled
smoke?" and assessing the appropriateness of the response. Perception may be
assessed by holding up a pencil and a pen to determine if the patient perceives the
difference. Memory can be assessed by saying certain words and asking the patient to
repeat them 5 minutes later.
The nurse is caring for a patient taking the anticonvulsant carbamazepine (Tegretol) for
idiopathic epilepsy. What is important for the nurse to monitor?
1. Changes in vision
2. Presence of weight loss
3. Complete blood count results
4. Condition of the patient's gums - Answer-3
Blood disorders are possible side effects of carbamazepine, as are drowsiness and
ataxia, so carefully monitoring of the results of a complete blood count is a priority, with
any significant changes to be reported to the physician. Gingival (gum) hyperplasia is a
side effect of phenytoin (Dilantin), and weight loss and vision changes are side effects
of topiramate (Topamax); these effects would not be expected with carbamazepine.
, A patient with lower back pain, pain radiating down the right leg, and some difficulty
walking reports recent episodes of incontinence. A herniation of which disks is most
likely responsible for these symptoms?
1. L2-L3
2. L5-S1
3. S4-S5
4. T11-T12 - Answer-2
The patient's symptoms of lower back pain, leg pain, and difficulty walking suggest a
herniated lumbar disk. Those symptoms combined with incontinence indicate that the
herniation is most likely in or includes the L5 and S1 disks. A severely herniated L5-S1
disk may affect bowel or bladder continence. This is an emergency situation and should
be reported to the physician immediately. Herniation of the L2-L3, S4-S5, and T11-T12
disks are not associated with episodes of incontinence.
The nurse has completed an assessment of the level of consciousness of a patient
admitted after a car accident. The nurse notes that the patient opens the eyes when
spoken to, uses inappropriate words when responding to questions, and withdraws from
pain. What should the nurse note as this patient's Glasgow Coma Scale?
1. 6
2. 8
3. 10
4. 12 - Answer-3
According to the Glasgow Coma Scale, a patient who opens the eyes in response to
verbal stimulus is scored a 3, a patient who uses inappropriate words in conversation or
in responding to questions is scored a 3, and a patient who withdraws from a painful
stimulus is scored a 4. The total Glasgow Coma Scale score (which ranges from 3 to
15) is 3 + 3 + 4 = 10 for this patient.
A patient is experiencing a new onset of delirium. When using the Confusion
Assessment Method, what information should the nurse prepare to collect? Select all
that apply.
1. Inattention
2. Acute onset
3. Disorganized thinking
4. Auditory hallucinations
5. Altered level of consciousness - Answer-1,2,4,5
When using the Confusion Assessment Method the following criteria helps diagnose
delirium: acute onset and fluctuating course, inattention, disorganized thinking, and
altered level of consciousness. Auditory hallucinations are not assessed when using this
assessment method.
A patient recovering from a spinal cord injury is inquiring about the use of stem cells to
promote regeneration. Which statements should the nurse include when assisting with
teaching? Select all that apply.
1. "Stem cells are used to improve mobility."
2. "Stem cells are used to improve sensation."
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