A nurse is caring for a client on a medical-surgical unit
Complete the following sentence by using the lists of options.
The client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Option 1: Intracranial hemorrhage: The client’s recent fall, worsening headache, unilateral pupil dilation, right-sided weakness, and decreasing Glasgow Coma Scale (GCS) indicate a potential neurological injury, which is concerning for intracranial hemorrhage.
Option 2: Glasgow Coma Scale: The client's GCS has progressively declined (from 15 to 13), indicating a decrease in neurological function, which is critical in assessing intracranial pressure and risk for hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Maintaining a healthy weight can reduce abdominal pressure, which may alleviate symptoms.
B. Sleeping with the head of the bed elevated helps prevent acid reflux, a common symptom of hiatal hernia.
C. Lying down after meals can worsen reflux, so it should be avoided.
D. Reducing caffeine and spicy foods can help minimize irritation of the stomach lining and reduce reflux symptoms.
E. Reducing fluid intake is unnecessary; fluids do not contribute to hiatal hernia symptoms.
Correct Answer is C
Explanation
A. A score of 6 indicates a severe impairment in consciousness, not alertness and orientation.
B. A score of 6 does not indicate a stable neurologic status but rather severe brain injury or impairment.
C. Clients with a GCS of 6 typically need total care, as they are unable to perform self-care activities and may be unable to respond to commands.
D. While a GCS of 3 indicates deep coma, a score of 6 reflects severe impairment, though not necessarily a deep coma.
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