A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?
The client requires total nursing care.
The client is in a deep coma.
The client is alert and oriented.
The client has a stable neurological status.
The Correct Answer is A
a. A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.
b. A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.
c. A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.
d. A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.
b. Taking the client's temperature is not the first action the nurse should take.
c. Notifying the charge nurse is important but not the first action the nurse should take.
d. Placing a dressing under the client's nose is not the first action the nurse should take.
Correct Answer is A
Explanation
If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or floor. This ensures that the traction is providing the appropriate amount of force to the affected limb.
The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.
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