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.
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Related Questions
Correct Answer is C
Explanation
The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.
Applying heat to the area of swelling for the first 48 hr, repeatedly asking the client questions to check for orientation, and encouraging the client to sleep for the first 24 hr are not appropriate instructions for the nurse to include in this situation. Applying heat can increase swelling and inflammation. Repeatedly asking the client questions can be disorienting and confusing. Encouraging the client to sleep for the first 24 hr is not necessary and could interfere with monitoring the client's condition.
Correct Answer is A
Explanation
a.Skeletal traction is often better than skin traction for reducing and maintaining alignment of a fracture because it involves the insertion of pins, wires, or screws directly into the bone, allowing for greater force and stability.
b.Clients in skin traction typically have less mobility compared to those in skeletal traction. Skin traction is usually used for short-term purposes or less severe fractures and involves attaching weights to the skin using adhesive materials or bandages, which can limit movement to some extent.
c.Skeletal traction involves inserting hardware into the bone, which creates an entry point for potential infection. Therefore, it has a higher risk for infection compared to skin traction, which does not involve invasive procedures.
d.While both types of traction can cause discomfort, skeletal traction is typically more invasive and can be associated with more discomfort and pain due to the pins or wires inserted into the bone. Skin traction, while uncomfortable due to the adhesive and pressure on the skin, generally causes less discomfort than skeletal traction.
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