Á nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
The client is alert and oriented.
Indicates stable neurologic status
The client needs total nursing care.
The client is in a deep coma.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Auscultating blood pressure may not be as reliable in burn patients due to fluid shifts and potential damage to peripheral tissues.
B. Monitoring pulmonary artery pressure provides crucial information about the cardiovascular system's status, including fluid balance and cardiac function, which are essential in the care of clients with severe burns.
C. Palpating pulse pressure alone is insufficient for thorough cardiovascular monitoring in critically ill burn patients.
D. Central venous pressure provides information about fluid status but does not offer the comprehensive cardiovascular data needed for extensive burn management.
Correct Answer is D
Explanation
A. Restlessness may indicate incomplete recovery or inadequate sedation reversal.
B. A brisk response to stimulus suggests the client is still in a mildly sedated state and not fully recovered.
C. A sluggish response to stimulus also indicates the client is not yet fully alert and oriented.
D. The client being cooperative and oriented is an indication of full consciousness and recovery from sedation, meeting discharge criteria.
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