ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse assesses a client with a brain injury. The client opens his eyes when the nurse calls his name, does not understand questions, and brings his arm up in response to a trapezius squeeze by the nurse. How would the nurse document this client's assessment using the Glasgow Coma Scale?
Correct Answer: D
Rationale: The correct answer is D: 9. The Glasgow Coma Scale (GCS) assesses eye opening, verbal response, and motor response. In this scenario, the client opens his eyes in response to a stimulus (4 points), has no verbal response (1 point), and exhibits localizing pain motor response by bringing his arm up to the trapezius squeeze (4 points). This totals 9 points on the GCS, indicating a moderate level of consciousness.
Choices A, C, and G are incorrect as they do not accurately reflect the client's assessment findings.
Choice B is incorrect as a score of 1 on the GCS indicates the lowest level of consciousness.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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