A nurse assessment of a client diagnosed with an acute loss of consciousness reveals a Glasgow Coma Scale (GCS) of 6.
Which nursing diagnosis is the priority?

Acute Confusion.

Self-Care Deficit.

Risk for Impaired Skin Integrity.

Ineffective Airway Clearance.

Answer and Explanation

The Correct Answer is D

Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.

Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.

Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.

A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.

Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.

Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.

A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.

Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.

Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.

A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.

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Correct Answer is B

Explanation

.“I need to receive 3 doses of hepatitis B vaccination to assure protection.” This statement indicates that the person understands that hepatitis B is a serious infection that can be prevented by vaccination.

Hepatitis B vaccine is given as a series of 3 shots over a period of 6 months.

Choice A is wrong because hepatitis A is not usually transmitted through unprotected sex, but through ingestion of contaminated food or water or direct contact with an infected person.

Hepatitis A can also be prevented by vaccination.

Choice C is wrong because hepatitis C can be transmitted through IV drug use, as well as blood transfusions, organ transplants, needlestick injuries, and sharing personal items such as razors or toothbrushes with an infected person.

Hepatitis C can cause chronic liver disease and there is no vaccine for it.

Choice D is wrong because there is a vaccine for hepatitis A, which can provide lifelong protection against the infection.

Hepatitis A usually does not require treatment and most people recover completely within a few weeks. There is no specific medication to cure hepatitis

A. Pulse of 126. B. Chronic fatigue. C. Hypoactive bowel sounds. D. Cold intolerance. E. Pulse of 54.

Correct Answer is ["B","C","D"]

Explanation

These are some of the common symptoms of hypothyroidism, which is a condition where the thyroid gland does not produce enough thyroid hormones. Thyroid hormones regulate the body’s metabolism, temperature and heart rate.

Choice A is wrong because a pulse of 126 is too high for hypothyroidism. Hypothyroidism usually causes a slow heart rate (bradycardia), not a fast one (tachycardia). A normal resting pulse rate for adults is between 60 and 100 beats per minute.

Choice E is wrong because a pulse of 54 is within the normal range for

hypothyroidism. Hypothyroidism can cause a pulse rate lower than 60 beats per minute, but this is not always abnormal. Some people, such as athletes, may have a lower resting pulse rate due to their fitness level.

The normal ranges for thyroid function tests are:

Thyroid-stimulating hormone (TSH): 0.4 to 4.0 milli-international units per liter (mIU/L).
Free thyroxine (T4): 0.8 to 2.8 nanograms per deciliter (ng/dL).
Total triiodothyronine (T3): 80 to 220 ng/dL.

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A nurse assessment of a client diagnosed with an acute loss of consciousness reveals a Glasgow Coma Scale (GCS) of 6. Which nursing diagnosis is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of middle age adults about various types of hepatitis. What statement by one of the group members indicates correct understanding of the differences?

Correct Answer is B

Explanation

A client has been newly diagnosed with hypothyroidism. What symptoms or signs would be expected with this diagnosis? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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A nurse assessment of a client diagnosed with an acute loss of consciousness reveals a Glasgow Coma Scale (GCS) of 6.
Which nursing diagnosis is the priority?