A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document?

Correct Answer: A

Rationale: GCS assesses eye opening (1-4), verbal (1-5), and motor (1-6). No response (eyes closed, no verbalization, no movement) scores 1+1+1=3 (A). Higher scores (B, C, D) require responses. A is correct. Rationale: A score of 3 is the lowest GCS, indicating deep coma, critical for documenting severe brain injury and guiding urgent care, per trauma assessment standards.

Correct Answer: B

Rationale: CPP = MAP - ICP; 90 - 15 = 75 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP of 75 mmHg is within normal (60-100), ensuring brain perfusion, per neurocritical care, critical for TBI outcomes.

Correct Answer: A

Rationale: A wellness nursing diagnosis best describes a clinical judgment of transitioning to a higher wellness level, focusing on enhancing health beyond mere absence of disease. Unlike pathology-based diagnoses, it identifies potential for growth like improving nutrition in a healthy client reflecting nursing's preventive role. Judging no pathology or more wellness than illness is narrower, missing the forward-looking aspect, while family strengths support interventions but aren't the diagnosis. This perspective encourages proactive care, aligning with wellness models to elevate client health.

Correct Answer: C

Rationale: The early phase of scar tissue formation is granulation tissue, rich in new blood vessels and collagen, aiding wound healing. Keloids are excessive scars, cicatrix is the final scar, and fibrous tissue is later-stage. Recognizing granulation informs nursing wound care, ensuring proper healing progression.

Correct Answer: D

Rationale: The other pupil constricts consensually when light hits one, a normal reflex. No change, dilation, or mixed response indicates abnormality. Nurses test this for brain function.